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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS:!��C* EN(S� <br /> �,l i✓� ( �( PERMIT SR #: <br /> ED 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, �c <br /> License #. 720 04 Expiration Date: 4/30/2022 <br /> Signature l I Title: President <br /> Print Name Karli Renae Stroing ( __Date_ <br /> �IK7 <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 #: 9115022-20 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 t"orkers compensation law of California. and agree that if I <br /> should become subject to workers' compensation pro isions of Section 3700 of the Labor Code. I shall <br /> forthwit corrlply with ose 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 /> I, Karli Renae Stroing <br /> _ hereby abthorize ( � G� <br /> me <br /> Nan1 C-57 L-rensed Authonmtl Represeniahve � Pnnt Name o dihon ed A e f i <br /> �v <br /> to sign this San Joaquin County Well & oring Permit Applicatio on my behalf. I understand this <br /> authorization is valid for one ye an Ii i d to the world plan dated n the front page of this application. <br /> Sign of 5, ices sed Ai7thor s n rive - - <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />