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San Joaquin County Environmental Health Department <br /> WELL He BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENS CNTRACTORS DECLARATION <br /> I nereby 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, nc. <br /> License#: 720904 il Expiration Date: 4/30/2022 <br /> Signature: I ) VAq a d Title: President <br /> Prin. Name: Karli Renae Stroing 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 /> 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 fo h this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to th work s' cope ation law of California, and agree that if I <br /> should become subject to workers' compe sation provisions f Section 3700 of the Labor Code, I shall <br /> f rthwith c pl ith those rovisions. <br /> Signature:—" VT/ <br /> P int Name: Karli Renae Stroing <br /> WARNING: FAILURE TO SECURE WORKERr OMPENSATION 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 31,706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PE IT APPLICATION <br /> Carli Renae Stroin <br /> I, 9 , hereb aItorize <br /> Name of C-57 Lcensed Authorized Representative pont Name of AuNo rite Agent <br /> to sign this San Joaquin C unty Well& oring Pe mcation on my behalf. I understand this <br /> authorization is valid for one ye an li it d to the dated on nt page of this application. <br /> Signe of C-57 Lidgnsed4AT, <br /> ze epres itattve <br /> EHD 29-01 6-23-2015 d Site Mitigation Well Permit Application <br />