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San Joaquin County Environmental Health Department <br /> WELL & O ING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: V 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#: 7 0 44/30/2020 <br /> Expiration Date: <br /> Signature: 01 Title: Presi ent <br /> Print Name: Karli Renae Stroing _ Date: L z <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 or which this permit is issued, I shall not employ any person in <br /> any manner so as to become s ject to th4 work s' compensation law of California, and agree that if I <br /> should become subject to work rs' compensation provisions of Section 3700 of the Labor Code. I shall <br /> rthwith eomply ith those provisions. <br /> �Signature: � <br /> Print Name: Karli Renae Stroing �\ <br /> WARNING: FAILURE TO SECURE W042KE S' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER''T 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 THA"-57 SIGNING PERMIT-APPLICATION <br /> I Karli Renae Stroing _ ereby authorize <br /> - - , <br /> Name of C-57 licensed Au[honiee Represr�Utrve Print Nano of Authorized Age t to sign this San Joaquin County We & Bori Permit Applicat n on my behalf. I understand this <br /> authorization is valid for on y @r a is i ited to a rk plan da don the front page of this application. <br /> nalum of - L Ihorved Represantahve - <br /> l <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />