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' I <br /> San Joaquin County Environmental ealth Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I�J �►N PERMIT SR#: <br /> 1 <br /> LIC NSED CONTRACTORS 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 Busines and Professions Code and my license is in full force and effect. <br /> l <br /> Contractor Name: V&W Drilling In . <br /> License#: 724 04 i Ex iration Date: 4/30/2022 <br /> Signature: �' '' Title: President <br /> Print Name: Karli Renae Stroing Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjuryone of the following declarations: (check one) <br /> I have and will maintain a c rtificate of consent to self-in sure for workers' compensation, as <br /> ❑ provided for by Section 3700 of the Labor Code, for the erformance 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#: 9115022-2 Exp. Date: 10/2/2021 <br /> I certify that in the performance of the work for-which this ermit is issued, I shall not employ any person in <br /> any manner so as to become subject to a wo kers' o pensati n law of California, and agree that if I <br /> should becomXE or ers' co pensati n pr vis ons of Section 3700 of the Labor Code, I shall <br /> forthw co ply t se provisions. <br /> Signature: <br /> Print Name: Karli Renae Stroing <br /> WARNING: FAILURE TO SECURE WO�KERS' 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 CODE <br /> 'W"t M, N_, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PQER T APPLICA,TnIO�N , <br /> I, Karli Renae Stroing h eby authorize L/J <br /> Na of C-57 Licensed Au honed Repmsenfatlue Prinl a ra of AUMonxM ent <br /> to sign this San Joaquin C unty Well&Borin Per 'it Applicat on on my behalf. I understand this <br /> authorization is valid for one ye ran ted to e w r Ian da ed on the front page of this application. <br /> 1 k <br /> , tum al C- mensed ut riled epres <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />