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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 2947 Golden Eagle Dr, Stockton, CA <br /> 2705 Golden Eagle Dr, Stockton, CA <br /> JOB ADDRESS: 2802 Golden Eagle Dr, Stockton, CA PERMIT SR#: <br /> rey aw , oc on, <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 /> 0904 C-5 "� <br /> License#: 7 ( r Expiration Date: 4/30/2022 <br /> Signature: "' Title: President/CEO <br /> Print Name: Karli R. Stroing Date' 8/11/21 <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 /> 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#: 9115022;20 Exp. Date: 10/2/2021 <br /> I certify that in the performance of the work f"hich this permit is'issued, I shall not employ any person in <br /> any manner so as to become st4bject to the wohkers' compensation law of California, and agree that if I <br /> should become subject to i6rkeirs',compensatign provisions of Section 3700 of the Labor Code, I shall <br /> fa f with comply with those provisions. <br /> Signature: 1 V V <br /> Print Name: Karli R. 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 $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Karli R. Stroing ,h r b authorize apace-Kuhl 8 Associates <br /> ame W C-57 Lwensnd Aulhor,zed RePtesontahva PNnt ame o.....l[ed Agent <br /> to sign this San Joaquin County Well,$t Borin�,Perrpit Application o my behalf.I understand this <br /> authorization is valid for one year a 6 is i ked to t woft plan dated an the front page of this application. <br /> i <br /> EH 29-01 6.23-2015 Site Mitigation Well Permit Application <br />