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{ <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: i r' ��' n� V�1 (, ``IO �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, In . <br /> License #. 72Q904 Expiration Date: 4/30/2022 <br /> Signature: ! 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 /> 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 /> I certify that in the performance of the wapenation <br /> ch this p is issued, I shall not employ any person in <br /> any manner so as to become subject ers' compe ation law of California, and agree that if I <br /> should become subject to orkers' co provision of Section 3700 of the Labor Code, I shall <br /> forthw �with those provisions. <br /> Signature: � vap�1, , , <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 PERM IT-AP PLICATION <br /> t <br /> I, Karli Renae Stroing , herebyV <br /> �� 17 <br /> Name of C-67 Licensed Autbonmtl Rep—nunve Pnm me Aut onzetl A nt <br /> to sign this San Joaquin C unty Well 8 ring Permation qn my ehalf. I understand this <br /> authorization is valid for on y 'and I a to the woated on the front page of this application. <br /> Signet of -S Licensetl Aut nz R resents i 7 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />