Laserfiche WebLink
License #. 720 04 Expiration Date: <br />Signature: Title: <br />Print Name: It / '7 <br />Contractor Name: V&W Drilling <br />Sig <br /> <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> <br />JOB ADDRESS: 140 Ft SE from Corner of HVVY 33 & Durham Ferry Rd PERMIT WP #: <br /> <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 />WORKERS' COMPENSA-TION 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 />0 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 insurnce carrier and policy numbers are: <br />Carrier: <br />I 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 subject,to the workers compensation law of California, and agree that if I <br />should become subject to workers' cOmpensation provisions of Section 3700 of the Labor Code, I shall <br />forth ith comply with those provisions. , <br />Signatur <br />Policy #: Date: h <br />Print Name: 0\_{ "1\C" <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATtOrsi 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 />, hereby authorize Gregor)) Stahl <br />Print Name of Authorized Agent <br />to sign this San Joaquin C unty Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for e ye r and is Ii i d to th work plan dated on the front page of this application. <br />I, Karli Stroing <br />Name of C-57 Licensed Authorized Representative <br />' kid IL& <br />-,cttr ,,reed •p sentati <br />END 29-01 8-1-2017 <br />Site Mitigation Well/Boring Permit Application