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Expiration Date: <br />Title: <br />DO <br />Date: <br />I certify that in the performance of the work f <br />any manner so as to become subject to <br />should become subject to workers' corn <br />forthwith <br />which this permit is issued. I shall not employ any person in <br />rkers' compensation law of California, and agree that if I <br />ensa ion proyiss of Section 3700 of the Labor Code, I shall <br />omply with those provisions. <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1245 W. 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 />mom,I <br />WORK S' 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 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 nstion . urance arrier and policy numbers are: <br />Carrier: 6 Ut 0cIY V2 Policy #: nis--b39- 117 Exp. Date: <br />License C5 -7209 #: <br />Signature: <br />Print Name: Karli Stroing <br />Signature _i_l .111 Allan <br />MIF 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 SIGNING PERMIT APPLICATION <br />I, Karli Stroing G ory Stahl <br /> <br />, hereby aluthoriz <br /> <br />, r <br />to sign this San Joaquin County Well & Be ring Pe t App4Catio4 on behalf. I understand this <br />authorization is valid for one yey and i limite to the wo k plan datec on e front page of this application. <br />liL., <br />,1 <br /> <br />i, .-4 7 il,\(‘U <br /> <br />S 9 itpLii <br />Print Name. Karli Stroing <br />Nine Of C-57 Licensed Authorized RepnitsantaUvo t Name of Authonzed Age nt <br />EHD 29-01 8-1-2017 Site Mitigation VVelllEoring Permit Application