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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1717 Sanguinetti Lane, Stockton, CA <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 0904( -57) 4/30/2022 <br /> expiration Date: <br /> Signature: <br /> Title: President/CEO <br /> Print Name: Karli R. Stroi Date: 7/19/21 <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 /> 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 /> State Fund policy#: Exp. Date: 10/2/2021 <br /> Carrier: 9115022-20 <br /> I certify that in the performance of the work foCAQ <br /> ich this permit is issued, I shall not employ any person in <br /> any manner so as to beco sub ct to the wor ers' compensation law of California, and agree that if I <br /> should become subject to orker compensate provisions of Section 3700 of the Labor Code, I shall <br /> fo hwith comply with those provisions. <br /> Signature: j l' <br /> Print Name: Karli R. Stroing <br /> WARNING: FAILURE TO SECUR RKERS' 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 SIGNWQPERMIT APPLICATION <br /> I, Karli R. Stroina ereby ar thorize i W Ilace-Kuhl&Associates <br /> -�nie L a tW Autlwrced eprnenfaNvnot Namo o/AV!onxetl ynt <br /> to sign this San Joaquin ounty We &Bori Per it Application n my behalf.l understand this <br /> authorization is valid for ne a a is Ii ited to a Per <br /> plan dated on the front page of this application. <br /> na0lwo C47 L- aP- <br /> EHD 29-016-23-2015 I Site Mitigation Well Permit Application <br />