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San Joaquin County Environmental Health Department <br /> WE LL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I <br /> I L I � �� ' PERMIT SR #: <br /> LL �1 <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 CaliforniaBusiness and Professions Code and my license is in full force and effect. <br /> Contractor Name: V Dril I , Inc. <br /> License#: 720904 Expiration Date: 4/30/2022 <br /> Signature: � L 1 '�{� Title: President <br /> Print Name. Karli Renae 8trcg Date: V� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty Df 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 /> R Labor Code, fort 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 beco aect to the workers`�cc pensation law of California, and agree that if I <br /> should become subject to rker ' compensation Prov Ions of Section 3700 of the Labor Code, I shall <br /> fo with comply with those provisions. <br /> Signature: i <br /> I-) � �� <br /> Print Name: Karli Renae 34iQ <br /> WARNING: FAILURE TO SE( URE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN Eh PLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO TH COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FO IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Karli Renae Stroing , here y au orize �ew -) �V I ,�C <br /> N.—of C-57 L.—d Aalhon¢ao Rap-mtenvra Pnnt NmN of AutlgnzM Agent <br /> to sign this San JoaquinCounty Well Boring P rmit Application on eha . 1 understand this <br /> authorization is valid for onnials <br /> li" . ed to the ork Ian dated on,the fron page of this application. <br /> Si atu o 37 cams A Rep- nM" <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />