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Contractor Name: V&W Drillin <br />License #: 720 04 <br />Signature: <br />Print Name: <br />ON DECLARATION <br />Expiration Date: L-1 <br />Title: <br />Date: <br />Karli Stroing, <br />Name of C-57 Licensed Authorized Representative <br />to sign this San Joaquin C unty Well <br />authorization is valid for • e ye r and is Ii <br />thorizeGre 0 ,, Stahl <br />Print Narne of Authorized Agent <br />Applic4tion on my behalf. I understand this <br />plan d ted on the front page of this application. <br />EHD 29-01 8-1-2017 <br /> <br />Site Mitigation Well/Boring Permit Application <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 140 Ft SE from Corner of HVVY 33 & Durham Ferry Rd PERMIT WP #: <br />LICENSED 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 />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 />co ensation ins retince carrier and policy numbers are: <br />Carrier: 1/1,1/\.. Policy #: Exp. Date: / /V/ /(7 <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 • the worker*co ensation law of California, and agree that if I <br />should become subject to workers' c mpen tion .rovisioi of Section 3700 of the Labor Code, I shall <br />forth ith qomply wi h those)provisions. <br />Signatur <br />1 <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSA 10 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 SIGNIN RMIT APPLICATION