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r <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> QAJOB ADDRESS:Ahla fi�ffw) PERMIT SR #: <br /> ------- ----------- <br /> LICE E CO Y4(QT <br /> ORS 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 #: 7209 _ -------.-,Expiration Date 4/30/2022 <br /> Signature: VTWXY 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 /> 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 /> I certify that in the performance of the wo k- which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject t the orkers' compensation law of California, and agree that if I <br /> should become subject to workers' co pen tion pr,"i ons of Section 3700 of the Labor Code. I shall <br /> forthwit comp with thdse provisions <br /> n 1 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 hereby authorize r✓ ' ' <br /> g - -_q- Y- - g - ed' t -- - <br /> N...o C-E Ucansen A V zcd Rep . tat,ve P t Name o A ori <br /> to sign this San Joaquin Count Well & Bonn Per it A lication on m alf. Fu derstand this <br /> authorization is valid for one y a pnd i limit to he w k plan dated on the fro page of this application. <br /> l� r <br /> Signature C57 Lice serf A nze pr sr tl iw - <br /> EHD 29-01 E-23-2015 Site Mitigation Well Permit Application <br />