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r <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: d O li� C % _ _ 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 Drillin rinc. <br /> License # 72990.4 Expiration Date: 4/30/2020 <br /> Signature: V Title: Presideqt <br /> Print Name. Karli Renae Stroing Date. lk <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 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 wok for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to The wor er ' compensation law of California, and agree that if I <br /> should become subject t workeV ' comlaensation p visions of Section 3700 of the Labor Code, I shall <br /> fsrthwith comply w# those provisions. <br /> Signature: I <br /> t <br /> , <br /> Print Name: arli 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 h9reby,puthoriz� I � <br /> Name of C• irent�horin opresentativa rint amo of uthor nt <br /> to sign this San Joaquin County Well & orin Permit Applicat on on my behalf. Ized understand this <br /> authorization is valid for one ea and 's li tt d to t e work plan d d on the front page of this application. <br /> I <br /> t <br /> Sipnat e 7 L¢e sea rizs r s ntnhve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />