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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: b-00 <br /> )(.'V_ PERMIT SR #: <br /> -- - -- - <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, In. <br /> License #: 720 04 _ Expiration Date: 4/30/2020 <br /> Signature: � Title: Presid nt <br /> Print Name: Karli Renae Stroing <br /> Date: \l <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 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 /> 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 beconi� subject to tf workers' compensation law of California, and agree that if I <br /> should become subject to wqrkers' compeTatlon provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> Signature: �` J• I� _ <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 THAN C-57 SIGNING PERMIT APPLICATION <br /> Karli Renae Stroing hereby authorize ;{ r(,� <br /> ema of C-5 LIC—ld A,.u,,,I nRup.asenis'�,�i---------- rint arneo ut -nnd Awt <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for on year ang�Ii ited to the work plan dated on the front gage of this application. <br /> f , <br /> S,qn tura 0<-57 LiCaniad onre0 R .er,tuti e� — <br /> J <br /> C;2f) _,1 5 23-2015 Site Mitigation Well Permit Application <br />