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• San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> f r <br /> JOB ADDRESS: o' ;�,--�— I�f(� PERMI <br /> TSR#: <br /> C-) I C1 — <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 & . ing, Inc. <br /> License#: 720 04 Expiration Date: 4/30/2020 <br /> Signature:Affit Title: Presid nt <br /> Print Name: Karli Renae ng 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 /> E3 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 /> R 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 performa ce of a work for which this permit is issued, I shall not employ any person in <br /> any manner so as to becMworker# compe <br /> o the w s' compensation law of California, and agree that if I <br /> should become subject tnsation rovisions ofSection 3700 of the Labor Code, I shall <br /> th comply ith those provisions. <br /> Signatur : WV <br /> Print Name: Karli Renae S join <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 PFERMIT <br /> l PLICATION <br /> 1, Karli Renae Stroing , hereby thorize d� 1 <br /> Name C37 Eicen u o zad epm"ntauve not aRMI o uthonz pant <br /> to sign this San Joaquin Co my Well 8 oring P rmit Application on my ehalf. I understand this <br /> authorization is valid for on y an limit d to the o plar2 dated on the ront page of this application. <br /> n .prawn <br /> 7 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />