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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 5113 E ain Street, Stockton, CA 95215 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& Iling r <br /> License#: 720904^ ti 4/30/2022 <br /> 1 r� Expiration Date: <br /> Signature: I ��,` `� Title: President/CEO <br /> arli R. Strom 11/19/2020 <br /> Print Name: 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 /> 0 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 /> ® L or Code, for thle performance of the work for which this permit is issued. My workers' <br /> co pensati ins rance carrier and policy numbers are: \ <br /> Carrier: 0Policy#: C C Exp. Date: Z� <br /> I certify tha In the performance," work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to th orkers' compensation law of California, and agree that if I <br /> should become subject to kers'�compens tion provisions of Section 3700 of the Labor Code, I shall <br /> fo' with com ly with those provisions. <br /> Signature: <br /> Print Name: Karli R. Stroi g <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 APPLICATION <br /> I, Karli R. Stroing ereby au orize Wallace-Kuhl & Associates <br /> tarns of CST Licensed Authorized Regimm antati" Prim Name of Authorized Agent <br /> to sign this San Joaquin County Well oring ermit Application n my behalf. I understand this <br /> authorization is valid for one earnd ' li i d to th w rk plan dated n the front page of this application. <br /> wtJ ! <br /> 1 nature C U A rued RepRwMatl <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />