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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> - 1 <br /> JOB ADDRESS: E ` a U,� c% PERMIT SR#: <br /> 1�N��LICEN� SED� 11� �� <br /> CONTRACTORS DECLA ATION <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#: 7209 } Expiration Date: 4/30/2020 <br /> Signature: L Title: Presid nt <br /> Print Name: Karli Renae Stroing Date: • <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 /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation law of California, and agree that if I t <br /> should become subject to workers' comp e 'sation provisions of Section 3700 of the Labor Code, I shall g <br /> % fort with c ply with those previsions. <br /> .Jf <br /> Signature: L <br /> Print Name: Karli Renae Stroing <br /> E <br /> WARNING: FAILURE TO SECURE WORKERS' PENSATION 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 APPLICA 1100 <br /> I, Karli Renae Stroing hereby authorize <br /> Name of C Ucanzed u oni Roprcs 10 v� P -Hams of Au Monxud Ayenl <br /> to sign this San Joaquin County Well& BoriJD n Permit Applicat n my behalf.t_ derstand this <br /> authorization is valid for one ye r anrYis li ited t �t a work pla dated on the front page f this application. <br /> signal n C It .a ul : rct D <br /> EHD 29-01 6-23-2015 Site Mitigation Well Pennit Application <br />