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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 the t I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of thelCalifornia Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: Vi& W Drilling, Inc. <br /> License#: 7209Q4 r +' Expiration Date: 4/30/2020 <br /> Signature: V �V ______Title: President <br /> Print Name: Karli R nae Stroing Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm undei(penalty of perjury one of the following declarations: (check one) <br /> I have a9d will maintain a certificate of consent to self-insure for workers' compensation, as <br /> IJ provided1for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is lissued.! <br /> I have ar d will maintain workers' compensation insurance, as required by Section 3700 of the <br /> 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 d 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 become s bject to workers' comp satin provisions�f Section 3700 of the Labor Code, I shall <br /> hwith c pl witth,those p ovisions. <br /> Signature: a <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 /> ADDITIO TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PRO IDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Karli Renae Stroing hereby horize v(d ��� L , o✓�av� <br /> j <br /> to sign this San Joaquin C my Well & Boring Pe it pplIcation on my behalf. I understand this <br /> authorization is valid for one e r and I to the or Ian dated on the front page of this application. <br /> EHO 2"1 6-23.2015 Site Mitigation Well Permit Appliratior <br />