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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: l t?Lj�7 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 #: 720 04 e Expiration Date: 4/30/2022 <br /> Signature: I l <br /> 9 U I� Title: President . <br /> Print Name: Karli Renae Stroing Date: l(,\ <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 /> 13 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#: 9115022-20 Exp. Date: 10/2/2021 <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 the workers' co ensation law of California, and agree that if I <br /> should become subject to workers' compensation provisio s of Section 3700 of the Labor Code, I shall <br /> forthwit mply with thos provisions. <br /> Signature: <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 APPLICATION <br /> arli Renae Stroin i <br /> 1, K 9 , hereby authorize <br /> Name of C-57 Licensed Autnonmd Repnsentstrve Pnm —of ZVO Agent <br /> to sign this San Joaquin County Well & B ring Permit ppli ation ort my ehalf. I understand this <br /> nd im <br /> authorization is valid for one e it d to the work pl dazed on the ront page of this application. <br /> Signature C i ossa utftor Rep sentauve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />