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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> n <br /> JOB ADDRESS:_ �-t PERMIT SR#: <br /> LICE D 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#. 720904 Expiration Date: 4/30/2022 <br /> Signature: ; U' Title: President <br /> Print 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 /> 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 /> I certify that in the performance of the rk r which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the'worke� ompensation law of California, and agree that if I <br /> should become subject to rkers' c mpensatiori pro isions of Section 3700 of the Labor Code. I shat; <br /> forth 'th omply,(with hose 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 /> 1, Karli Renae Stroing 'by authorize bp�r� c r (,► <br /> Name o}C-87 L,censetl Authontetl epresuntative Print ttM of ut rl• Aqe t <br /> to sign this San Joaquin County Well & Bori g Permit Application on my behal . understand this <br /> authorization is valid for one ye ran thit;ed to he ork plan Old on the front page of this application. <br /> of C- UC sed mhon.ReprYent rve <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit application <br />