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` San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> jj II rr 1 �n <br /> JOB ADDRESS: 1 l�' V� l�� F-�/ 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 & rifling, Inc. <br /> License#: 720 04 _ Expiration Date: 4/30/2020 <br /> i <br /> Signature-&- __Title: Pre Iden <br /> Print Name. Karli Renae roing Date: l GI <br /> WORKERS' COMPENSATION DECLARAT ON <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 #: 9115022-19 Exp. Date: 10/2/2020 <br /> I certify that in the performance of the work for hich this pe it is issued, I shall not employ any person in <br /> any manner so as to become subject to thew rkers' compe ation law of California, and agree that if I <br /> should become subject to orkers' compe ation provisionsof Section 3700 of the Labor Code, I shall <br /> forthwith c ply with those revisions. <br /> Signature: <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 SIGNING PERMIT APPLICATION <br /> I, Karli Renae Stroing h reby authoriz �� ��' l �t 1� !; �1 <br /> Name of C.S7 Ltcensed Authored Representative Pnnt Name of Authonzed Allent <br /> to sign this San Joaquin Cou ty Well oring ,ermit Applicati n on my behalf. I understand this <br /> authorization is valid for one a -and 1 limit d to the wo plan dat d on the front page of this application. <br /> b, tt"" <br /> S.gnat a of C57 Licensed uth ed opre ntnhve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />