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<br />to sign this San Joaquin County Well &13- ring Per t Applatio behalf. I understand this <br /> <br />to the wok plan date e front page of this application. <br />re of C,47 Licensed preunta ve <br />authorization is valid for one yea and i Jim <br />Karli Stroing G ory Stahl <br />Nurne of Authcrunni Agent <br />, hereby <br />Nero of C-67 Licensed Authorized Representative <br />thoriz <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1245W. Charter Way, Stockton, CA 95206 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 Drillin Contractor Name: <br />License #: C5 -72 <br />Signature: <br />Print Name: Karli Stroing <br />Expiration Date: <br />Title: I <br />Date: <br /> <br />WOR S' COMPENSATION DECLARATION <br />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 />0 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued <br />)1( 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 />comp nsapon . urance carrier and policy numbers are: Ft <br />I certify that in the performance of the work f r which this permit is issued. I shall not employ any person in <br />any manner so as to become subject to e rkers' compensation law of California, and agree that if I <br />should become subject to workers' corn ensa ion provisars of Section 3700 of the Labor Code, I shall <br />forthwith ornply wi h those provisions. <br />Signature: <br />Print Name: <br /> Karli Stroing <br />WARNING: FAILURE TO SECURE WORK 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 SI NING PERMIT APPLICATION <br />Carrier: Policy #: t111.5133- <br />tti-(1) <br />Exp. Date: <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application