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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> AJOB ADDRESS: ftkL4 l k PERMIT SR #: <br /> L NSED 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, I . <br /> License #: 720 04 Expiration Date. 4/30/2022 <br /> Signature: —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 /> O 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 worklfo—rv�hich this permit is issued: I shall not employ any person in <br /> any manner so as to become subjeM�0-6� <br /> kers <br /> pensation law of California, and agree that if I <br /> should become subject to workers' p(vi ions of Section 3700 of the Labor Code I shall <br /> orti h th se provisions. <br /> Signature: U <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 hereb auth�grize <br /> _— L G <br /> �.._._-- ----- —= <br /> Nama of G•'SI llcansed Arnhorizad Rapreuantahvu Print ame of Authoritrd gent <br /> to sign this San Joaquin County Well & Boring Pe mit Application on my behalf. I u derstand this <br /> authorization is valid for one y ar//and ig Ii to to the ork Ian dated an he front page of this application. <br /> ignat re of -6T Licensed mtw Rep nentaUve l <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />