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San Joaquin County EnvIronmenta Health Department <br />WELL & BORING PERMIT APPLIC 'TION SUPPLEMENTAL <br />JOB ADDRESS: VZS— IV) • Oil VI ..,C)( <br />LICE <br /> <br />-c\' -t <br />ECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapt r 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Code a my license is in full force and effect. <br />PERMIT SR #: <br />Contractor Name: V & W Drilling, )rfc-.) <br />License #: 7 04,, 20 <br />Signature: .1) <br />Print Name: Karli Renae Stroing <br />• iration Date: 4/30/2022 <br />Tile: President <br />te: 5b5i,j4 <br />WORKERS' COMPENSATION DEC ARATION <br />I hereby affirm under penalty of perjury one of the following declardtions: (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, forth performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insuran as required by Section 3700 of the <br />Labor Code, for the performance of the work for which his permit is issued. My workers' <br />compensation insurance carrier and policy numbers ar • <br />Carrier: State Fund Policy #: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> law of California, and agree that if I <br />ection 3700 of the Labor Code, I shall <br />isions. <br />I <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATilp , ,, - <br />I, Karli Renae Stroing <br /> , I n i / <br />Name of e-rl Leconood /unnamed fteptesootatfoo <br />, here thorize, i in 1/Sitil Yr/4 Ot f ki V\11A4/V, 1' , i .. , / -- \ Noma of Autho Ag t I <br />to sign this San Joaquin County Well & Boring Permit Applicat on orj my behalf. I understand this <br />authorization is valid for one yea and • lim d to th wor plan dated o the front page of this application. <br />11\a,t_ ')L? <br />,).01C-67LsemasdA pni$110 <br />'"" <br /> <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 OF1COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application