Laserfiche WebLink
License #: 720904 <br />Signature: <br />Print Name: Karli Renae Stroing <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />r <br />JOB ADDRESS: ,,%1C j ' Cii r <br /> PERMIT SR #: <br />ae4“ <br />LICENSED <br />00— <br />CONTRACTORS DECLARATION <br />I hereby affirm that I am licenSed und.r the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the California usine nd Professions Code and my license is in full force and effect. <br />Contractor Name: V & W Drillin4, I <br />Expiration Date: 4 /30/2022 <br />Title: Presi entl . <br />Date: 9 LA d I <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury cne of the following declarations: (check one) <br />0 <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 carr er and policy numbers are: <br />Carrier: State Fund Policy #: Exp. Date: 10/2 /2021 <br /> <br />I certify that in the performance of the work for which this pyrmit is issued. I shall not employ any person in <br />any manner so as to become subject I o the workers' compensation law of California, and agree that if I <br />should become subject to workers' compensation provisibns of Sectickn 3700 of the Labor Code, I shall <br />forthwith comply WO tIpseprovision, <br />Oa,/ <br />, <br />I <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 <br />o <br />Nam, al C.51 Licanscd Autnor.od Rrn n.th,t <br />, hereby iuttioriz WI i ( li,i ,.? <br />Pnnt Nam f Aunt riled Agent L, <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one yeaj and' unity to the work plan dated on the front page of this application. <br />1 <br />) , 7 <br />) 1 <br />5' g Wren/C.5i Licenned • utho 2(tes'''Lltnt(e k.67 <br />(t <br />Signature: <br />Site Mitigation Well Permit Application <br />EHD 29-01 6-23-2015