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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 1 <br /> JOB ADDRESS: PERMIT SR #: <br /> .. .. .... .... <br /> , C <br /> LICENS D CONTRACTORS DECLARATION <br /> I hereby affirm that I am licnsed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Californi Business and Professions Code and my license is in full force and effect. <br /> Contractor Name. V & W Drilling, Inc. <br /> License #: 7209q4 Expiration Date: 4/30/2022 <br /> Signature vj, ' Title President <br /> Print Name Karli Renae Stroing C <br /> DateCIO <br /> � <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty f perjury one of the following declarations: (check one) <br /> I have and will ma ntain a certificate of consent to self-insure for workers' compensation, as <br /> 13 provided for by Selction 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 f=und Policy #: 9115022-20 Exp. Date: 10/2/2021 <br /> I certify that in the performance of the work for which this perm' is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers' compen ation law of California, and agree that if I <br /> should becomesub ect to II orkers' compensation provisions Section 3700 of the Labor Code. I shall <br /> forthwith coZjh those pr visions. <br /> Signature - t <br /> 16 <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 THEA 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 APPLICATION 1 <br /> 1, Karli Renae Stroing _ , hereby authorize Y j I <br /> Name of C-57 Licensed Authof¢ed Represrnteuve �t amt pent <br /> to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one e r anq is limit d to the wk plan dated on the front page of this application. <br /> Signet n A tart epnantattve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />