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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR#: <br /> LIE SED�� CI ONTRACTORS 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#: 720904 Expiration Date: 4/30/2020 <br /> Signature: I Title: President <br /> Print Name: Karli Renae Stroing % Date: r' <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 /> 13 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 /> IP 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 r whic this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers compensation law of California, and agree that if I <br /> should become su ject to w rkers' compensation pr isions of Section 3700 of the Labor Code, I shall <br /> forthwith d'omply with hose provisions. <br /> I W�u Signature: : ' ' <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 APLICATI N <br /> ; i <br /> 1, Karli Renae Stroing , hereby allthJda <br /> Nuns of - ions uthon"d pft r UtW* nt o tlwn Al"J4 K"t5 <br /> to sign this San Joaquin Co my Well Boring�err�nit Apn on my behalf. I understand this <br /> authorization is valid for one y r a,is t1lited to t�e ork pld on the front page of this application. <br /> p [uno (/L� fpnun <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />