Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1�� &qo ( V VI+- <br /> '��/ PERMIT SR #: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7 000) of <br /> Division 3 of the California Busin ss and P ofessions Code and my license is in full force and effect <br /> Contractor Name: V & W Drilling, nc. <br /> License#: 7209 4 Expiration Date 4/30/2020 <br /> Signature: Title: President <br /> Print Name: Karli Renae Stroing Date: <br /> WORKIERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation. as <br /> 13 provided for by Section 3700 of the Labor Code. for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are <br /> Carrier: State Fund _ _ Policy #: 9115022-19 Exp. Date: 10/2/2020 <br /> I certify that in the performance ofwprk for hich this permit is issued. I shall not employ any person in <br /> any manner so as to becomes bject td the w rkers' compensation law of California. and agree that if I <br /> should become su4iect work s' compensa on provisions of Section 3700 of the Labor Code. I shall <br /> �� rth th comply with those provisions. <br /> Signature?,; _ <br /> Print Name: Karli Renae Stroi <br /> WARNING: FAILURE TO SECUR W KERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000. IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST. ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Karli RStroing <br /> I _ hereby authorize <br /> `lama of CLicensM Auihor1i«Ienae Rnp�e•,��nie��:.-. ... -...- - r t roof AuthoNzM gent <br /> to sign this San Joaquin County Well & Baring Permit Application on m�behalf. I understand is <br /> authorization is valid for one y ary�nd is,iimi a to th wor)t Ian dated on th_ !!front page of this application. <br /> neun sed <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />