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I <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 255 W. Legacy Drive, Mountain House, CA PERMIT SR#: <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#: 7209 4 , Expiration Date: 4/30/2020 <br /> Signature: 1 Title: Pres dent — <br /> Print Name: Karli Renae Stroing Date: la a /A/ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have a d will maintain a certificate of consent to self-insure for workers' compensation, as <br /> 17 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 a d will maintain workers' compensation insurance, as required by Section 3700 of the <br /> IR Labor Cc de, for the performance of the work for which this permit is issued. My workers' <br /> compen ation insurance carrier and policy numbers are: <br /> Carrier: State Fu id Policy#: 9115022-19 Exp. Date: 10/2/2020 <br /> I certify that in the performance of the work forh this permit is issued, I shall not employ any person in <br /> any manner so a to become subject to t work s' compen ation law of California, and agree that if I <br /> should becomes jbject to workers' comp satiorY provisions f Section 3700 of the Labor Code, I shall <br /> hwith c pl with those p ovisions. <br /> Signature: <br /> Print Name: KarliRenae 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 /> ADDITIO TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PRO DED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I <br /> Karli Renae g <br /> Str�trn vra � <br /> `t , hereby{ horize V <br /> to sign this Sah�"Joaquin C my Well & Boring Pe it Application on my behalf. I understand this <br /> authorization Is valiq for one e r and Ii to the or Ian dated on the front page of this application. <br /> I <br /> EHD 28-01 6-23-2015 Site Mitigatlan Well Permit Application <br />