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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Stockton, CA 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 Drillin "INC. <br /> License #: 720 04 Expiration Date: 4/30/2020 <br /> Signature: 1 �'? Title: Preside t <br /> Print Name. Karli Renae Stroin Date: lo/q <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 /> 13 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: <br /> re:Carrier: State Fund Policy #: 9115022-18 Exp. Date: 10/2/2019 <br /> 1 certify that in the performance of the r which this permit is issued, I shall not employ any person in <br /> any manner so as to become subje to the ork compensation law of California, and agree that if I <br /> should become subject to workers' mpen at io pr visions of Section 3700 of the Labor Code, I shall <br /> j� forth 'th comply!wit those provisions. <br /> Signature: <br /> Print Name: 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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Karli Renae Stroing , hereQyautorize Condor Earth Technologies <br /> Name of C.57 Licensed Authorized Representative Print Name of Authorized Agent <br /> to sign this San Joaquin County Wl oring Ppplicatio on my behalf. I understand this <br /> authorization is valid for one jtfll i "t dto thelan ate on the front page of this application. <br /> r <br /> Signet o/C 7 Licensed t ed Represen hve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />