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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 1 , <br /> 1 � <br /> JOB ADDRESS: UX R, CAP. <br /> PERMIT SR#: <br /> C T7 <br /> ICENSED 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, In. <br /> License#: 720 04 Expiration Date: 4/30/2020 <br /> Signature: 1 Title: Pre ident <br /> Print Name: Karli Renae Stroing j Date: 117) <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check on <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 bV Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issu d 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 work foF-which this, mit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' comp nsation law of California, and agree that if I <br /> should become subject to workers' compensation provisio of Section 3700 of the Labor Code, I shall <br /> �fort1hwith'com ly with tlho provisions. <br /> Signature: , `l( <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 FINS UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY't FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT�/APP/-LIICATItO/N� <br /> 1 Karli Renae Stroing , h red by a. thorize ✓ JJ1 17,1 l� I <br /> Name o C-S Licensed Aud-read Representative not Name o/Au oozed A-ent <br /> to sign this San Joaquin County Well Boring ermit Applicat' n on my behalf. I understand this <br /> authorization is valid for one y r a d is ' tted to th work plan da ed on the front age of this application. <br /> 1 <br /> J 1 <br /> oat t C- Llcan Au[ :ed entmve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />