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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ( !h (h1 "Co �V� I PERMIT SR #: <br /> k)'�\_ 0, <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#: 720 04 Expiration Date: 4/30/2020 <br /> r1 A <br /> Signature: Title: Presi ent <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 /> 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 performance of the work,for W�{{ch this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the work �s' co ensation law of California, and agree that if I <br /> should become subject to workers' com ensation provisio S of Section 3700 of the Labor Code, I shall <br /> n forthwith comply.with thos provisions. <br /> Signature: ..)(��Ak <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 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 SIGNI PERWT APPLICATION <br /> Karli Renae Stroing <br /> I, 9 , hereby aut rtze , <br /> Name of 0-57 Licensed Authonzed Representative Pnnt Name of Autiwnzed Agent <br /> to sign this San Joaquin County Well & Boring Per it Application on my behalf. I understand this <br /> authorization is valid for one ye an is li to thew k Ian d� ed on he front page of this application. <br /> gnatu of -67 Licensed Au rizad ,ue—tative 1 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />