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Site Mitigation Well Permit Application <br />Signet ntadve °seised Repro <br />to sign this San Joaquin County Well & Boring P rmit pplication on my behalf. I understand this <br />authorization is valid for one year and ' Ilmi to the orlkplab dated on the front page of this application. <br />EHD 29-01 6-23-201 <br />Karli Renae Stroing , herepy a horize Name ot C.57 Liceosed Authorized Representative <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNIN PERMIT APPLICATION <br />'7 c ) • <br />Expiration Date: 4/30/2022 <br />JOB ADDR <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />SS: (91 ) j PERMIT SR #: <br />0,q))1\ I tier— <br /> <br /> <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of 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*: 72004 <br />Signature: <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 /> <br />I certify that in the performance of the work for whic is permit is issued, I shall not employ any person in <br />any manner so as to become subject/to the workers' ompensation law of California, and agree that if I <br />should become subject to workers' c mpensation projiisions of Section 3700 of the Labor Code, I shall <br />forth h mply 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 />Print Name: Karli Renae Stroing <br />Title: President i <br />)ci Date: