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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />J013 ADDRFSS: I�[� �� uVC ,(,1 'C - PERMIT SR #: <br />__.._---- ------- --- <br />LICENSED ONTRACTORS [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 />ontractor Name: V & W Drilling, Inc <br />License #: 7209Q4 --- ------------ - <br />`xpiration Date: 4/30/2022 <br />Signature L �{i T 11e: President <br />Print Name: K�irli Renae Stroing _ _late: <br />WORKERS' COMPENSATION DE LARATION <br />I hereby affirm lander penalty of perjury one of the following declar tions: (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 370P of the Labor Code, for the performance of the work for which this <br />perrnit is issued. <br />I have and will maintain workers' compensation insurar ce, as required by Section 3700 of the <br />Lab(Dr Code, for the performance of the work for which his permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: State Fund <br />Policy #: 9115022-'10 Exp. Date: 10/2/2021 <br />I 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 become subject to the workers pensation law of California, and agree that if I <br />should becorne subject to workers' compensation provis ons of Section 3700 of the Labor Code, I shall <br />("\` forthwith comply with th se pro isions. <br />lXr-h I)i,- � `� <br />Signature: <br />Print Name: Karli Renae Stroin <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION OVERAGE 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 />AU I HUK14A I IUN FOR OTHER THAN C-57 SIG <br />�Karl-yi Renae Stroing hereby author <br />NJ111y p{ (.6'J t.ieenead AithcrzoJ Rop�cr.eniativ—��^i ---- <br />to sign thio San Joaquin County W II & Boring Permit Apoli <br />authorization is valid for one1yej)f anA41111611ed to the work plan <br />PP <br />n on my behalf. I understand this <br />d on the front page of this application. <br />EHE 29-01 6-23-2015 1 Site Mitigation Well Permit Application <br />