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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: \jSSU�� � 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 CalifPgia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V &,W Drilling, Inc- � <br /> i <br /> License#: 720 0VRenSt <br /> Expiration Date: 4/30/2020 <br /> Signature: Title: Presid nt <br /> Print Name: Karli 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 /> IP 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 /> 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 <br /> should become su ject to rker ' compensation provisions of Section 3700 of the Labor Code, I shall <br /> f rthwith co with those provisions. <br /> Signature: <br /> Print Name: Karli Renae Str m <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 P R IT APPLICATION/) <br /> r A / <br /> I Karli Renae Stroing , hereby authori e <br /> Name of C-57 Le:ented Authorized Roprcsenteove ' V pnnof Authonz' Agent <br /> to sign this San Joaquin Coun Well & Bor ng Permit Application on my be alf. I understand this <br /> authorization is valid for one ea nd 1s1' itdd o the w rk pan dated on the fro t page of this application. <br /> gnaturc Licensed Authon prcaentative <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />