Laserfiche WebLink
Contractor Name: V & W Drilling, Inc <br />License #: 7209,04 <br />Signature: <br />Print Name: Karli Renee Stroing <br />Expiration Date: 4/30/202/4 <br />Title: Preident <br />Date: 1/f Li <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 36 GarCre 10( 6-1,{— <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 />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 /2022 <br /> <br />I certify that in the performance of the work for whicL <br />any manner so as to become subject to the worker <br />should become subject to workers' compensation <br />orthwith co <br />Signature: <br />Print Name: Karli Renae Stroing <br />this permit is issued, I shall not employ any person in <br />' compeh-s ion law of California, and agree that if I <br />rovisions of ection 3700 of the Labor Code, I shall <br />isions. ply With those pr <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 SIGNIN P MIT PPLICA <br />t r 1, Karli Renee Stroing , her Øy aut,orIze 1.10.i.111. ti Name a-e-57LIconsoi 971--rizerl199presentailve rthorized <br />to sign this San Joaquin County Well & Boring ermit pplication on my .ehalf. I unders and this <br />authorization is valid for o r arid Is +Red to th work plan dated on the front page of this application. <br />t <br />1 1,, I/ <br />r, Ao. 'Lod Au .k2 <br />FHO 29 01 6-23-2015 Site Mitigation Well Permit Application