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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ���L � �( I i� �' PERMIT SR #: <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,(_Inc <br /> License # 720904, 1 r Expiration Date: 4/30/2022 <br /> r <br /> Signature I �.1�'n 1�� Title President <br /> Print Name Karli Renae Stroing 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 /> 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 for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject-te�he work s' compensation law of California, and agree that if I <br /> should become subject to workers'(comp nsation .rovisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply w�th those provisions <br /> Signature �, �� V <br /> Pant 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 <br /> 1PERM T APP ICATION <br /> 1, Karli Renae Stroing _ hereby authorize no/ <br /> Name of C-57 L-n AUlhori:ed Represent,Ft Prinl dme of Aulho nZed Agenl `\ <br /> to sign this San Joaquin County Well & Loring Per it application on behalf. I understarl this J <br /> authorization is valid for one ye and illi it d to thew rk plan dated on the front page of this application. <br /> Sign Lure u -5 licensed Auth nz&`d Represenlafive <br /> I� <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />