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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Acfm i PERMIT SR #: <br /> (L'I'', <br /> ENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the pr ons of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Profess ns Code and my license is in full force and effect. <br /> Contractor Name: V & W Drilling, In . <br /> License#: 7209JO4 Expiration Date: 4/30/2020 <br /> Signature: Title: President <br /> Print Name: K rli 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 wopoor ich this permit is issued, I shall not employ any person in <br /> any manner so as to become subWr <br /> sation law of California. and agree that if I <br /> should become subject to workerSection 3700 of the Labor Code, I shall <br /> foe ovisions. <br /> �', k , N, <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 /> 1• Karli Renae Stroing hereby au rize Aq__ <br /> •..i•..r;1:'.,, ..i.uc1 Ai.ttivi:.:tl R•P«•ti• I:.t,';- M W q�n! <br /> to sign this San Joaquin County Well & Boring Per it Ap lication on my beha f. I understand this <br /> authorization is valid for one year a`nd is lliimite to the w rk n dated on the front page of this application. <br /> of C47 uceffl"77pm� <br /> N <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />