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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT /APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: l l,Q GCS E(�n uF-d PERMIT SR #: <br />t L4 CA -- <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-Rrilling, Inc <br />License #: 720PO4 i ' / Expiration Date: 4/30/2020 <br />Signatur : Title: Pre 'den <br />Print Name: Karli RE�ae roing Date: <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: <br />State Fund policy#: 9115022-19 Exp. Date: 10/2/2020 <br />I certify that in the performance of the work for hich this p 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 provisions of Section 3700 of the Labor Code, I shall <br />forthwi c ply with those rovisions. <br />Signature:,,K, J <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 THA <br />I Karli Renae Stroing , hreby a <br />Nn of C-67 Lr %&d uthort: epm ume <br />to sign this San Joaquin Cou ty Well "oring hermit Appli <br />authorization is valid for one ye ,,and ip_lirrgt d to the\wo#t plan <br />ERMIT <br />on my behalf. I understand this <br />on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />