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San J aquin County Environme <br />WELL & ORING PERMIT APPLI <br />JOB ADDRESS: IN YVI W <br />LICENSED CONTRA TOS F <br />Health Department <br />'ION SUPPLEMENTAL <br />PERMIT SR #: <br />ECLARATION <br />I hereby affirm that I am licensed ui�ider the provisions of Chaptr 9 (commencing with Section 7000) of <br />Division 3 of the California Business and Professions Code an my license is in full force and effect. <br />Contractor Name.- V & W Drilling, / nc. <br />License #: <br />Signature: I IN <br />Print Name: Karli Renae Stroinq <br />I hereby affirm under penalty of perju ' <br />ll one of the following declal <br />I have and will maintain a FIrtificate of consent to self - <br />provided for by Section 37of the Labor Code, for th <br />permit is issued. <br />I have and will maintain wdrkers' compensation insura <br />Labor Code, for the performance of the work for which <br />compensation insurance carrier and policy numbers al <br />Carrier: State Fund Policy #: 9115022- <br />I certify that in the performance of the work for which this permit i <br />any manner so as to become subject t e orkers' penso. <br />should become subject to workers' mpen tion provisl ns of <br />(� fort ith comply with:tho pro <br />1 r, r I <br />Signature: � �A,U 'WIA <br />Print Name: Karli Renae Stroinq <br />ration Date: 4/30/2022 <br />Presi en <br />:ions: (check one) <br />sure for workers' compensation, as <br />performance of the work for which this <br />R, as required by Section 3700 of the <br />is permit is issued. My workers' <br />Exp. Date: 10/2/2021 <br />Issued, I shall not employ any person in <br />on law of California, and agree that if I <br />vection 3700 of the Labor Code, I shall <br />sions. <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION C VERAGE 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, INTERE T, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR C DE <br />I, Karli Renae Stroing reby aut ort; <br />am. o c cern u ed .ry..eenlrirve <br />to sign this San Joaquin Co}�nty Well & Borin Permit ppli <br />authorization is valid for one �e�r and js I_irr Ited to e w pan <br />//� . jam, i i <br />01my"behalf. I understand this <br />or the front page of this application. <br />EHD 29-016-23-2015 1 1 1 1 Site Mitigation Well Permit Application <br />