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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR #: <br /> ENSED CONTRACTORS DECLARATION <br /> I hereby affirm that i am licensed under the 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#: 720 4Expiration Date: 4/30/2020 <br /> Signature: ya Title: President <br /> Print Name: K di Renae Stroing Date <br /> WORKERS MPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> 0 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 performanceof the wo for ich this permit is issued, I shall not employ any person in <br /> any manner so as to become subject t the w rk6rs' com sation law of California, and agree that if I <br /> should become subject tow kers' co pens i n provisions Section 3700 of the Labor Code, I shall <br /> forthwi c with Chase,, ovisions. <br /> Signature: LIM <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 authorize (11 tJrp— <br /> nrt <br /> to sign thisSa <br /> U}45 Li<.C��tlG{A A fI)Gft2i�R4{�rv'xei1lHf�ve..__.`._ <br /> g n Joaquin County Well & Boring Per it Application on beha f. I understand this <br /> authorization is valid for one year,and is limi)e to the w rk n dated on a fron page of this application. <br /> n <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />