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License #: 720 04 Expiration Date: 4/30/2022 <br />Signature: <br />Print Name: Karli Renae Stroing <br />Title: President <br />Date 04/13/2021 <br />Contractor Name. V & W Drilling, Inc. <br />T APPLICATIO/ <br />nt Nm. of rtze Agent 6 (4)/tde - <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PER <br />Karli Renae Stroing , hereby authorize <br />Name of C37 Licensed Authonzed Representative <br /> <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1880 E. Hammer Lane, Stockton PERMIT SR #: <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 />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 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 insurance carrier and policy numbers are: <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 subject to the workers' co ensation law of California, and agree that if I <br />should become subject to workers' compensation provisio s of Section 3700 of the Labor Code, I shall <br />forthwit' • s mply with thos provisions. <br />Signature: <br />Print Name: Karli Renae 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 />to sign this San Joaquin County Well & Boring Permit <br />authorization is valid for one ye nd imit d to the work <br />pplication on my ehalf. I understand this <br />pIa dared on the ront page of this application. <br />END 29-01 6-23-2015 Site Mitigation Well Permit Application