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San Joaquin County Envirr-,,irnental Health Depaornent <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �Gft(D-13141D ' 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 #: 72090 Expiration Date: 4/30/2020 <br /> Signature: ) ! _N'V V Title President <br /> Print Name: Karli Renae Stroing Date: <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 /> I certify that in the performance of the work for which this permit is issued. I shall not employ any person it <br /> any manner so as to become subject to the workers' compensation law of California. and agree that if I <br /> should become subject to workers' comp satioh provisions Section 3700 of the Labor Code. I shall <br /> 1rthwith m with thos p visions. <br /> _�Signature � ^ v. <br /> Print Naine: Karli 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 /> AUTHORIZA"iJUN FOR OTHER HAN C-57 SIGNING PERMIT APPLICATION <br /> 1 Karli Renae Stroing _ hereby authorize <br /> Narnr of C-57 L—sed Authonreo Rcprese,,u c., Pnnt A'aino o1 Authorized Agent <br /> to sign this San Joaquin County Well & ring Per, it Application on my behalf. I underst d this <br /> authorization is valid for one ea nd is-,limited to the Per <br /> ork plan dated on the front age of this application. <br /> Signal of Licensed Auth z epresenta ive <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />