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if tI) <br />License #: 7209 <br />Signature: <br />WARNING: FAILURE TO SECUR WCR <br />SUBJECT AN EMPLOYER <br />ADDITION TO THE COST OF <br />AS PROVIDED FOR IN SECTI <br />ERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />0 CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />N 3706 OF THE LABOR CODE <br />AUTrIORIZATION FOR OT ER THAN C-57 SIGNING PERMIT APPLICATION <br />an Joa uin County Environmental Health Department <br />WE9_ & B RING PERMIT APPLICATION SUPPLEMENTAL <br />s <br />JOB ADDRESS: q61 NC) 11. OV PERMIT SR #: <br />LI <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 Drillin , Inc. <br />EVE fl— <br />D &TRACTORS DECLARATION <br />Expiration Date: 4/30/2022 <br />Title: President a <br /> Date: 1 1 c9-1 <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 />provided for by Sect*, 3700 of the Labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will maint in 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 insurance carrier and policy numbers are: <br />Policy #: <br /> issued, I shall not employ any person in , — any manner so as to become subject o the workers" ompensation law of California, and agree that if I <br />should become subject to workerslc mpensation pro./ isions of Section 3700 of the Labor Code, I shall <br />fort‘h ith comply with Ithose provisions. (-1 • <br />(—Al. <br />Print Name: Karli Renae String <br />Karli Renae Stroing <br />Norms of C-57 Licon•od Authofuoti Roprosentotive <br />to sign this San Joaquin County W <br />authorization is valid for one year nd i <br />EHD 29-01 6-23-2015 <br />II & Boring Permit Application on behJi. I understand this <br />mitea o the work pl n dated on the front page of this application. <br />9nalu <br />, herefutt—;): ize Gi 114-0— <br />Site Mitigation Well Permit Application <br />Print Name: Karli Renae Stroin