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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS:, ` rq— PERMIT SR #: <br />NSED <br />I hereby affirm that I am licensed under the provisions of Chapter(commencing with Section 7000) of <br />Division 3 of the Califomia Business and Professions Code and v license is in full force and effect. <br />Contractor Name: V & W Drilling, Inc. <br />License #: 7200-0904 ' Ex iration Date. 4!30/2022 <br />Signature: VVIj, w Title: President <br />Print Name: Karli Renae Stroing Date: <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 t is permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: State Fund Policy #: 9115022-20 Exp. Date: 10/2/2021 <br />1 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 th rkers' compensation law of California, and agree that if I <br />should become subject to workers'co. <br />nsa ion provisi s f Section 3700 of the Labor Code, I shall <br />forthw�th kollkly.with those rove sions. <br />Signature: �1 ►/�� ��L <br />, <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 C DE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNI PERMIT APPLICATION <br />I, Karn Renae Stroing , herebOHA <br />rize <br />e ap�m nave nl ofwMM root <br />to sign this San Joaquin County Well & Boring Peplic on on,r t� half. I understand this <br />authorization Is valid for one yeir and 1"mitefl to the n da ed on the ont page of this application. <br />EHD 29-01 6-232015 1 1 Site Mitigation Well Pen -nit Application <br />