Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I` <br /> JOB ADDRESS: qcl)0 d C'l v��2, 1 �� PERMIT SR#: <br /> LICE 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#: 72 904 Expiration Date: 4/30/2020 <br /> Signature: CI l / A Title: Presid nt <br /> Print Name: Karli Renae Stroing Date: C <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#: 9115022-18 Exp. Date: 10/2/2019 <br /> 1 certify that in the performance of the worke hich this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to w rkers' comperis ion law of California, and agree that if I <br /> should become subject to workers' co pens ion provisions o Section 3700 of the Labor Code, I shall <br /> forthwit com ly with tho `e pr visions. <br /> Signature: <br /> Print Name: Karl) Renae Stroing <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 SIGNING P MI -APPLICATION 11 <br /> I, Karli Renae Stroing hereby a orize <br /> N.—W C Lican• A.tho.ucd apnaa Wi- , u I o .Agani <br /> to sign this San Joaquin County Well & Boring Permit pplication on my behalf. I understand this <br /> authorization is valid for one year n 's li ited the work andated on the front page of this application. <br /> of C Uc sad u.o ad ogres ml va <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />