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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />1145 W. Charter Way, Stockton, CA 95206 JOB ADDRESS: <br /> <br />PERMIT WP #: <br /> <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 />V&W Drilling, nc. Contractor Name: <br />Expiration Date:1-4 2-C) <br />Signature: Alu 1,4 Title:W?1ctL <br />Print Name: Karli Strcing ) 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 />1:1 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 />compensatio . suran carrier and policy numbers are: <br />Carrier: k ,1/4\r6 Policy #: ( Exp. Date: <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 o rs' compensation law of California, and agree that if I <br />should become subject to workers' compe satio, provisions ofSetion 3700 of the Labor Code, I shall <br />forthwith c ply with those provisfons. ( <br />arli 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 />Karli Stroing , hereby 'tho e <br /> Gryggy Stahl <br />C License #: 57-720904 <br />Signature: <br />Print Name: <br />Name of C-117 Licensed Authorized Rep reentallue Herne of Authorised Adorn <br />to sign this San Joaquin County Well & oring Pe <br />authorization is valid for one y ar and ' lim to the w <br />Ap ication on my behalf. I understand this <br />p,lin dated On thg front page of this application. <br />1 <br />EHD 29-01 8-1-2017 <br />Site Mitigation Well/Boring Permit Application