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f <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 2421 W Lowell Ave, 535 Mabel Josephine Dr, 151 W Lowell Ave, 650 W 10th St, 1701 S Central <br /> Ave, 1280 S Dove Dr, 1750 W Kavanagh Ave, 350 E Mt Diablo Ave, 800 Carlton Way, 501 Mt Oso <br /> JOB ADDRESS: Ave, 1550 E Cypress Dr <br /> PERMIT SR#: <br /> LICENSED 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 Business and Professions Code and my license is in full force and effect. <br /> Contractor Name.V&W Drilling <br /> License#: 7 904 (C-57) <br /> Expiration Date: 4/30/2022 <br /> Signature: ,Tittle: President/CEO <br /> Print Name: Karli R. StroingDate: 5/25/21 <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 /> 13 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 /> State Fund <br /> Carrier: Policy#: 9115022,20 Exp. Date: 10/2/2021 <br /> I certify that in the performance of the wor which this permit is;issued, I shall not employ any person in <br /> any manner so as to become subject the rkers' c mpensatton law of California, and agree that if I <br /> should become subject to workers'co pensa`tion pc vise ns of Section 3700 of the Labor Code, I shall <br /> forthw h comply w4h th a provisions. <br /> Signature: <br /> Print Name: Karli R. Stroing L <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 CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> h Karli R. Stroino _, her y aut'orize Wallace-Kuhl&Associates <br /> Name of C-6]Lwensatl un mvd .pr. tWva to sign this San Joaquin CountyWell Boring ermit Application o��l derstand this <br /> authorization is valid for one ye 'r an is limi d to t wort plawri dated of this application. <br /> n n of C lac Ibpnwntof v. <br /> I <br /> € <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br /> i <br />