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Expiration Date:I-4 2-0 1 <br />Date: C-21(1 <br />Title: <br />License C57-720904 #. <br />Signature: <br />Print Name. Karli Stroing <br />k_rz <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1141W. Charter Way, Stockton, CA 95206 <br />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 />Contractor Name: V&W Drilling, fh-c. <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 />0 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 />compensation surance carrier and policy numbers are: <br />Carrier: Policy #: C11 92191:3- 17 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 theffiblicl3rs' compensation law of California, and agree that if I <br />should become subject to workers' compe sation provisions of Se tion 3700 of the Labor Code, I shall <br />orthwith c ply with those provisions. <br />Signature: <br />Print Name: 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 Gr ory Stahl <br />, hereby a,n1hor e <br />P,4 Name ol Authon.rect Agent Name of C.-157 Licensed:I Aulhori.ed Representative <br />to sign this San Joaquin County Well & <br />authorization is valid for one y ar <br />oring Pe it Application on m behalf. I understand this <br />to the w k plan dated pn th front page of this application. <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application