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0 0 ✓�( p l 7 13 <br /> ✓m, J <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1600 Durham Ferry, Tracy, CA 95376 PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 /> License#: <br /> C57-720904 Exp Date: 4/30/2014 <br /> 5/31 13 ntr ctor: v&w Drilling <br /> Date: <br /> President <br /> Signature: <br /> Karli Stroin Title: <br /> Print Name: <br /> WOR S' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> —1 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 /> xx 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 Compensation Ins Fund Policy Number: 9026354-12 <br /> 1 certify that in the performance of the work for which this permit is i ed, hall not employ any <br /> person in any manner so as to become subject to the workers' c mpensati n law of California, <br /> and agree that if I should become subject to workers' C mpens io rovision of Se 0 of <br /> the Labor Code, I shall forthwith comply with those pr isi ns. <br /> 10/1/2013 Signature: <br /> Exp. Date: <br /> Karli Stroing <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SH L SUBJ CT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST O ENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Karli Stroing (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Ray Kablanow , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> EH02MI WOV12 <br />