Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ' G� ' ��, G�al <br /> PERMIT SR#: <br /> 1 G��— <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V&W Drilling, Inc. <br /> License#: 720994 nExpiration Date: 4/30/2022 <br /> Signature: �� Title: Pres ent <br /> Karli Renae Stroing \ 1 <br /> J q <br /> Print Name: g Date: <br /> WORKERS' 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 /> 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#: 9115022-20 Exp. Date: 10/2/2021 <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subje o the workers' compensation law of California, and agree that if I <br /> should become subject to workers' c m ensation> rovisions of Section 3700 of the Labor Code, I shall <br /> forthlith c mply wi those provisions. <br /> Signature: <br /> Print Name: Karli Renae Stroing <br /> WARNING: FAILURE TO SECURE WORKERS' 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 /> 1 Karli Renae Stroing , h reby a thorize <br /> Name of CS7 Licensed Aethor a d Representative �PIN. a of uthorized Agent <br /> to sign this San Joaquin County Well& Boring ermR Applic tion n my behalf. I understand this <br /> authorization is valid for on y r arts-is I ited to th work plan date on the front page of this application. <br /> i / 1 <br /> S nature of C57 Uad eprese rive <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />