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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> f <br /> JOB ADDRESS: I v ' Y,VL:� I yLl� � PERMIT WP#: <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 l 1 Expiration Date: <br /> Signature: ii <br /> 9 `` � Title: �' � .) 10 4+ <br /> Print Name: l lG Date: <br /> i <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 /> 4 Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> cornpen ation insur nce carrier and policy numbers are: <br /> Carrier: ` ;� Policy#: �.'� I ��� Exp. Date: 1 <br /> I certify that in the performance of the wor for which this permit is issued, I shall not employ any person in <br /> any manner so as to''become subject to th} 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 /> forthwith comply with those provisions. <br /> Signature: 1,� <br /> Print Name: !/ <br /> WARNING: FAILURE TO SECURE WORKERS'l-r MPENSATION 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 /> �AUTH RIZ�yATION 11FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereb authorize <br /> ` Name of CS7 Licensed Authorized Reprea tative Print Name of Au horiz gent <br /> to sign this San Joaqu�County Well&;Boring Per it Application on my behalf. I understand this <br /> authorization is valid for one r,bar anqAs liTited to the Mork plan dated on the front page of this application. <br /> A <br /> / r <br /> Si re f C-57 Ll zd Authorized Representative <br /> EHD 29-01 07-01-2025 Site Mitigation Well/Boring Permit Application <br />