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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> . <br /> JOB ADDRESS: � �C� PERMIT SR #: <br /> LICENSED CONTRALTORS DECLARATION <br /> 1 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, nc. <br /> License#: 720 04 Expiration Date: 4/30/2020 <br /> r <br /> Signature: _ i % Title: Pres'dent <br /> Print Name: Karli Renae Stroing Date: ` C <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 performance of the work f which this it is issued, I shall not employ any person in <br /> any manner so as to become subject to th workers' compe sation law of California. and agree that if I <br /> should become subject to work compen ation provision of Section 3700 of the Labor Code. I shall <br /> f rthwith co I with thos provisions. <br /> Signature: <br /> 41, " <br /> Print Name: Karll 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 hereby authorize In <br /> hamn of C-57 Licensed AUNonzea Reprcsmtahve punt of Autl,o zod Agent <br /> to sign this San Joaquin County Well & ring Per4 ",cppation on my behalf. I understand this <br /> authorization is valid for one ye r a d i i • to the wldated on the front page of this application. <br /> tpma -b— <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />