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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> i r <br /> JOB ADDRESS: �� I C. 1���ZY`C��"U PERMIT SR #: <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 & W Drilling, Inc. <br /> License #: 720994 Expiration Date: 4/30/2020 <br /> Signature: �41) ) Title: President <br /> Print Name: Karli Renae Stroing Date: 1— i �1 <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 /> 13 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 �y Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is Isslued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: State Fund Policy #: 9115022-18 E�p. Date: 10/2/2019 <br /> I certify that in the performance of the work for which this permit is issued, I shall 'hot employ any person in <br /> any manner so as to become 5-ybject to the orkers' compensation law of California, and agree that if I <br /> should become subject to \�6rkers' compens ion provisions of Section 3700 oflthe Labor Code. I shall <br /> forthwith com ly with those provisions. <br /> Signature: <br /> Print Name: Karli Renae Stroin <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 PERMLT APPLICATION <br /> 1, Karli Renae Stroin <br /> 9 , her y a thorize � � L' l <br /> Name of C-57 Licensed AuthonnA Represanwnve Pr,m Name of ut nzatl Age <br /> to sign this San Joaquin County Well Boring ermit Application n my behalf, I understand this <br /> authorization is valid for o e y ran is i �ited to t work plan date on the front page of this application. <br /> n of CS7 4c sae A t R presents ve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />