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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1mYt PERMIT SR #: <br /> C/r <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#: 7 09 4 Expiration Date: 4/30/2020 <br /> Signature: AAV4 Title: Presi ent <br /> Print Name: Karli Renae Stroing 'J Date: <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 become subject to rkers' compensation law of California, and agree that if I <br /> should become subject to workers' com ensa "on provisions of Section 3700 of the Labor Code, I shall <br /> forthwit co ply with thgW provisions. <br /> Signature: <br /> vatap ) b N"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 /> 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 APPLICATI01i <br /> I, Karli Renae Stroing , hereby aut <br /> a o icensed uthonr apmsentHwe r Printorne of Authaftwipent <br /> to sign this San Joaquin County Well & Boring Permi ApplicAtion on my beh I understand this <br /> authorization is valid for one TeaPand mite to the wo plaq dated on the frontp ge of this application. <br /> n o u pnaen w <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />