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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 & W Drilling, Inc. <br /> License#: 72 04 Expiration Date. 4/30/2020 <br /> Signature: i Title: Presid nt <br /> Print Name: Karli Renae Stroing Date. <br /> W014KE"' 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 #: 9115022-19 Exp. Date: 10/2/2020 <br /> I certify that in the performance of the worfo 'which this permit issued, I shall not employ any person in <br /> any manner so as to become subject tote workers' compens4tion law of California, and agree that if I <br /> should becomes bject to workers' com ns tion provisions o Section 3700 of the Labor Code, I shall <br /> forthwith or�iply with those provisions. <br /> Signature: 6 <br /> Print Name: Karli Renae Stroing <br /> I <br /> WARNING: FAILURE TO SECURE WORK 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 PLICATION <br /> 1, Karli Renae Stroing hereby auth-ori7,e U <br /> Nana of C-57 Licensed Authorized Representative Pnnt Name o AuMonznd Agent <br /> to sign this San Joaquin Count Well 8 Bo "ng Permit Application on my behalf. I understand this <br /> authorization is valid for one year d i mite o the work plairidated on the front page of this application. <br /> Signature of C-57 Licensed A.tho RepoestolatNt <br /> (�J <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />