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. i <br /> i <br /> an Joaquin County Environmental Health Department <br /> WEL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: n IrU� � C—</� <br /> PERMIT SR#: <br /> L LENSED ' ONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed urpder the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the California Busine$s and Professions Code and my license is in full force and effect. <br /> i <br /> Contractor Name: V&W Drilling, I <br /> License#: A24 Expiration Date: 4/30/2022 <br /> Signature: L Ti e: Pre -ides <br /> Print Name: Kadi Renae Stroing <br /> Date: O"� <br /> WORKEBS' COMPENSATION DEC RATION <br /> I hereby affirm under penalty of perjury one of the following declara ions: (check one) <br /> I have and will maintain a certificate of consent to self-i sure 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 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#: 91 15022-2D Exp. Date: 10/2/2021 <br /> I certify that in the performance of thew for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subje to t e workers' o ensati n law of California, and agree that if I <br /> should become subject to workers' omp nsation p ovisi ns of Section 3700 of the Labor Code, I shall <br /> fortwit mply w th�4 th se provisions. <br /> Signature: <br /> . tb 1 0 <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 kND 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 CC DE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNIP G PERMIT APPLICATION <br /> I, Karli Renae Stroing , her y author6 <br /> to sign this San Joaquin County Wt <br /> Bori g Pe mit Appllcati on my behalf.I unders this <br /> authorization Is valid for one y ar a isted to he rk Ian da d o the front page of this application. <br /> I <br /> smog <br /> n 7d"d .pr...n <br /> i <br /> EHD 29-01 6-23-2015 <br /> Site Mitigation Well Permit Application <br /> I <br />