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San Joaquin County tinvironmental Health Department <br />WELL & BORING PER IT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: <br />LI NSED 0 TRACTORS IpECLARATION <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 Drilli <br />Signature: <br />Print Name: Karli Renae Stroing <br />WOPiK 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-i sure for workers compensation, as <br />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 insuran e, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which t is permit is issued. My workers' <br />compensation insurance carrier and policy numbers ar <br />Tit e: Preside <br />Date: 1„7/idi <br />License #: 720 04 Expiration Date: 4/30/2022 <br />PERMIT SR #: <br />Carrier: State Fund Policy #: Exp. Date: 10/2/2021 <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 subjed to the workers' compensat on law of California, and agree that if I <br />should become s bject to workers' compensation provisions of ection 3700 of the Labor Code, I shall <br />) forthwith.tomply with th se prov sions. <br />. r , <br />Signature: <br />Print Name: Karli Renae Stroing <br />WARNING: FAILURE TO SECURE WOR ERS' 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 />1, Karli Renae Stroing <br /> Name of -57 Licensed Authorized Representative <br />, hereby authorize i lilt \glta-•-nrf,,d kin <br />.--- <br />nt a _ _ z__ • gent <br />---..1 to sign this San Joaquin County Well & 4 ring Permit Applicat on n my behalf. I understand this <br />authorization is valid for one year ,d is unite to the work plan dated n the front page of this application. / <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application