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1 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR #: <br /> MZA cC�. <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm th t 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 #: 720994 t Expiration Date. 4/30/2020 <br /> 2 Signature: } ��V Title: President <br /> Karli Renae Stroin ) l <br /> Print Name: 9 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 ad will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor C de, for the performance of the work for which this permit is issued. My workers' <br /> compen tion insurance carrier and policy numbers are: <br /> Carrier: State Fui id Policy #: 9115022-19 Exp. Date: 10/2/2020 <br /> 1 certify that in the performance of the work for whi(;i this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compen ation law of California, and agree that if I <br /> should become s bject to workers' compensation provisionstvisions.Section 3700 of the Labor Code, I shall <br /> fo hwith co ,pl with,11- p <br /> nI �1 <br /> Signature: <br /> Print Name: Karli Renae Stroing <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJEC. 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 APPLICATI <br /> n <br /> 1, Karli Renae Stroing <br /> hereby au�horize <br /> ame <br /> -.(C 57 Lxena uMon:ed RepresenUtive hnot Nama o uthonzed Aqen <br /> to sign this Salt Joaquin CoNnty Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one e r and.4 lupi d to the workplan dated on the front page of this application. <br /> SZ Wtun or .5 L¢ umor ed qo re en n <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />