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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 6545 EMBARCADEk) OR, STOCKTON, CA 95215 PERMIT SR #: <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 Businese and Professions Code and my license is in full force and effect. <br />Contractor Name: V & W DRILLING NC <br />piration Date: 4/30/2022 <br />Print Name: <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 ceitificate of consent to self-i <br />provided for by Section 3700 of the Labor Code, for the <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 />compen ation..insurance carrier and policy numbers r; <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />Print Name: V.4\1 I \ <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 />Signature:_ <br />n v‘i <br />'Iforthwith ctmly with those/Provisions. <br />- <br /> <br />Exp. Date: ii0;9-1?"1 <br />WARNING: FAILURE TO SECURE WORKERS' COMFIENSATION COVERAGE IS UNLAWFUL, AND SHALL <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 />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />UTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />it) <br />ine <br />authorization is valid for one ye r and is li,tn) thted to the wo ,k plan dated on front page of this application. <br />c Ahonzeeprecentative <br />License #: 720904 <br />Signature: btt) Ti le: PrCAtt <br />frtt") Date: 1-uar, <br />sure for workers' compensation, as <br />performance of the work for which this <br />Carrier: tik Policy #: <br />to sign this San Joaquin County Well & Boring Permit Applicaton on my behalf. I understand this <br />Authorized Represenla e <br />Pont Name of Authorized Agent <br />Ito <br />, herebyieuthodze Jesus Lopez Larios of Wallace-Kuhl & Associates <br />Site Mitigation Well Permit Application EHD 29-01 6-23-2015