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JOB ADDRESS: <br />LICE <br />PERMIT SR #: <br />ONTRACTORS DECLARATION <br />San Jo quin County Environmental Health Department <br />WELL & B RING PERMIT APPLICATION SUPPLEMENTAL <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 />p License #: 72004 <br />Signature: <br />Print Name: Karli Renae Stroing <br />Title: Pre idea r <br />dal Date: .1 <br />Expiration Date: 4/30/2022 <br />WORKER' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury ne of the following declarations: (check one) <br />0 I have and will maintain a ce ificate of consent to self-insure for workers' compensation. as <br />provided for by Section 370 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will maintain wor ers compensation insurance, as required by Section 3700 of the <br />Labor Code, for the perform nce of the work for which this permit is issued. My workers' <br />compensation insurance car ier and policy numbers are: <br />Carrier: State Fund <br />I certify that in the performance of the ork for which, his permit is issued, I shall not employ any person in <br />any manner so as to become subject 1e-the workers' compensation law of California, and agree that if I <br />should become subject to workers' cdmpensation pr visions of Section 3700 of the Labor Code, I shall <br />) forthvOlh eomply with those provisions. <br />Signature: t ti/L-' I UkCe'k <br />-,..) <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 />Policy #: 9115022-20 Exp. Date: 10/2/2021 <br />Print Name: Karli Renae Stroing <br />Karli Renae Stroing , hereby authorize Name ot C.57 Licensed Author, ed Representative <br />( <br />to sign this San Joaquin County Wel & Boring Permit Application o <br />authorization is valid for one ye r and is li ited to the work plan dated o <br />uti, nat e .1 C. c onsed'Reprosentatis <br />o ol Au? ed gent <br />my behalf. I understand this <br />the front page of this application. <br />EHD 29-01 6-23-2015 <br />Site Mitigation Well Permit Application