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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: <br /> PERMIT SR#: <br /> LICED CON R T <br /> ORS 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 an my license is in full force and effect. <br /> Contractor Name: V& W Drilling nc. <br /> License#: 72 904 <br /> Expiration Date: 4/30/2022 <br /> Signature: Ti le: Pr si�di nt <br /> Print Name: <br /> Ka Renae Stroing D te: (T} <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 /> 0 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 insuran e, 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 /> I certify that in the performance of thefor which is permit is issued, I shall not employ any person in <br /> any manner so as to become subje tot a workers'compensation law of California, and agree that if I <br /> should become subject to orkers' mpensation pr visions of'Section 3700 of the Labor Code, I shall <br /> forth ith,com.pyy wit those prov sions. <br /> Signature: <br /> Print Name: Kadi 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 C F COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SEC ION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR O HER THAN C-57 SIGNI G PERMIT APPLICATION <br /> I, Karli Renae Stroing , hereby u orize b VADSflq� ) { . <br /> Wme e/ - ena Aull,orized N•pn••nW • ul OMI <br /> to sign this San Joaquin County Well& Boring Pe it Applicatl n n m behalf.I understa d this <br /> authorization is valid for one ye r d i to the ork Ian date on t front page of this application. <br /> JAW <br /> Ignalu Ipms u on •presenhNw <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />