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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: If2J <br /> 7 (v U, PERMIT SR #: <br /> LICENSED C NTRACTORS 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, In - <br /> License#: 72090 Expiration Date: 4/30/2020 <br /> Signature: I I Title: Pre si ent <br /> Print Name: Karli Renae Stroing Date: L'{ <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 wor for wh h this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to he workers' compensation law of California. and agree that if I <br /> should become subject to wor rs' comp nsation provision ofection 3700 of the Labor Code, I shall <br /> c <br /> orthwith mp with those pro v sions. <br /> Signature:_"k, i /-iM �, �� <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 APP CATION <br /> I, 1� A <br /> Karli Renae Stroing , her�y au orize � ;� <br /> Na r of C.57Licensed A,11,or a,1 Representative ( Na o Au wn ed Agonl <br /> to sign this San Joaquin C unty We & Boring Permit Application on my b half. I understand is <br /> authorization is valid for on y r a s i ited to th6l wor plan dated on the ront page of this application. <br /> J I T) <br /> R of C-57 Lrcen uVr aptes�ntauw <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />