Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS:__ p(�r Gun <br />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 Business and Professions Code and my license is in full force and effect. <br />Contractor Name: V & W Drilling, Inc.//.. - <br />License #: 720904 <br />Expiration Date: 4/30/202 <br />Signature: __'�(�/l (J_1: (/ Title: President <br />Print Name: Ka�rli R`enae Stroing Die; <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 <br />Policy #: 9115022-20 <br />I certify that in the performance of the work for <br />any manner so as to become subject to the <br />should become subject to workers' coml- - <br />;::., ,--forthwith co <br />Signature: � . I'A'w.111 t': -) <br />Print Name: Karli Renae Stroi <br />Exp. Date: 10/2/2022 <br />this permit is issued, I shall not employ any person in <br />compens ion law of California, and agree that if I <br />rovisions of ection 3700 of the Labor Code, I shall <br />th those pr isions. <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 <br />I, Karli Renae Stroing , he <br />--Fiam.-J-6:'srr.e <br />to sign this San Joaquin County Well & Boring <br />authorization is valid for orW y9br apd is4ited to tl <br />C-57 SIGNING PERMIT APPLICA' <br />orize nt of u11LizM g <br />rit pplicatig4t on m ehalf. I unders and this <br />plan da0d on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation well Permit Application <br />