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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />2421 W Lowell Ave, 535 Mabel Josephine Dr, 751 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'CONTRACTO <br />I hereby affirm that I am licensed under the provisions of Chal <br />Division 3 of the California Business and Professions Code <br />f <br />Contractor Name: V&W Drilling <br />License #:*72;0 4 (C-57)Signature:Print Name: arR. Stroing <br />ECLARATI <br />9 (commencing with Section 7000) of <br />my license is in full force and effect. <br />tion Date: 4/30/2022 <br />President/CEO <br />5/25/21 <br />WORKERS' COMPENSATION DtCLARATION <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 />State Fund Policy #: Exp. Date: 10/2/2021 <br />Carrier: 9115022120 <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 mpensaton law of California, and agree that if I <br />should become subject to workers' Co pensa ion p vise ns of lection 3700 of the Labor Code, I shall <br />forth w h comply with th a provisions. <br />Signature:411a0 <br />R f <br />VURV <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 />MU i MUM1141A 11Ury t -UK U I titK THAN C-57 SIGNING PERMIT APPLICATION <br />1, Karli R. Stroina , her y aut orize Wallace -Kuhl & Associates <br />Name Of C�S7 L im, Aub,.. epro Ufive nt Name b yeat <br />to sign this San Joaquin County Well r Boring ermit AppilaatJ n on y behalf. I understand this <br />authorization is valid for one year an is limd to t work pl rated on the front page of this application. <br />t P t n p 9 pp <br />EHD 29-01 6-23-2075 I Site Mitigation Well Permit Application <br />