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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1245 W. Charter Way, Stockton PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 Cade and my license is in full force and effect. <br /> Exp License <br /> C57-720904 EX Date: 11/1B/2013 <br /> #: <br /> CON <br /> ontra tor: <br /> V&W Drilling <br /> Signature: Title: <br /> 4rl i <br /> Print Name: <br /> ORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty c f perjury one of the following declarations: (check one) <br /> _I have and will main in a certificate of consent to self-Insure for workers' compensation, as <br /> provided for by Secti n 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> X <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 /> State Find Policy Nu 91026354-13 <br /> Carrier: Y <br /> 1 certify that in the pe ormance of the work for which this p mit is issued, Zhal <br /> person in any mann so as to become subject to the work s' compensatand agree that if I sh Lid become subject to workers' compens 'on provisio <br /> the Labor Code, I she I forthwith comply with those rovi ions. <br /> Ex Date: 10/1/2014 Signature: i <br /> p- <br /> Karli Stroin <br /> Print Name: <br /> WARNING:FAILURE TO SECURE VI7 KERS'C PENSATION COVERAGE IS <br /> A D OST SHALL <br /> SUBJCOMECT <br /> NEMPLOYON, RESER O <br /> CRIMINAL PENALTIES A D CIVIL FI ES UP TO $1oo,000, N ADDITION TO <br /> ATTORNEY'S FEES,ANd AMAGES AS PROVID OR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHOR IZAT F THER T C-57 SIGNING PERMIT APPLICATION <br /> Karli Stroing trsta <br /> /(signature of C•57 licensed authorized representative), <br /> lana ; to sin this San Joa uin County Well & Boring Permit <br /> hereby authorize(print name) 9 qApplication on my behalf. I his authorization is valid for one year and is limited to the work <br /> plan dated on the front page c I this application. <br /> WELL PERMIT APP <br /> EHO 29-01 09W112 <br />