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i <br />San Joaquin County Enviror <br />WELL & BORING PERMIT AP <br />JOB ADDRESS: ►�S �! . UV1 <br />LICENSD (�t"SNTR <br />Health Department <br />TION SUPPLEMENTAL <br />PERMIT SR #: <br />ORS DECLARATI <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 Busines� and Professions Code an my license is in full force and effect. <br />Contractor Name: V & W Drilling, <br />License #: 720904 <br />Signature: R,�,(,11 �Myy j <br />Print Name: Karli Renae Stroinq <br />iration Date: 4/30/2022 <br />President <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 />13 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: <br />r :Carrier: State Fund Policy #: 9115022-20 Exp. Date: 10/2/2021 <br />I certify that in the performance of the work for which this permit i <br />any manner so as to become subject to the1workers' compense <br />should become subject to workers' compegsation provisiof <br />forth ith comply with tho7spro <br />Signature: <br />Print Name: Karli Renae Stroing <br />issued, I shall not employ any person in <br />on law of California, and agree that if I <br />ection 3700 of the Labor Code, I shall <br />sions. <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 OFjCOMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />I <br />TION FOR OTHER THAN <br />1, Karli Renae Stroing , hereb�thorize <br />I,— C- lkan�ed u0ior ed e�roa¢ntativa <br />to sign this San Joaquin County Well & Boring Permit Applic; <br />authorization is valid for one yea7and j%,lirrtl ed to th�worl�plan d <br />!JP N <br />my behalf. I understand this <br />the front page of this application. <br />EHD 29-016-23-2015 1 Site Mitigation Well Permit Application <br />