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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: I ' " Ida PERMIT SR #: <br />LICENSED �QA&TQRS 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, Inc. <br />License #: 72 04 Ex 3iration Date: 4/30/2022 <br />Signature: LACTitl : President <br />Print Name: Karli Renae Stroing Dae: <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 wor hich this permit is issued, I shall not employ any person in <br />any manner so as to become subject tilthe w rkers' co a sation law of California, and agree that if I <br />should become subject to workers' co pens ion provisions of Section 3700 of the Labor Code, I shall <br />A— 0forthwit corrwlv_with those ibrovisions. <br />Signature: <br />Print Name: Karli enae Stroin <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 CGDE <br />I, Karli Renae Stroing , hereby authorize <br />nu of C.97 Licansad Authoep-tsli" <br />to sign this San Joaquin <br />authorization Is valid for ones <br />EHD 29-016-23-2015 <br />Well & Boring Perm <br />As llmlfald to the wo <br />on,rhy bapalf. I understand this <br />on the fr nt page of this application. <br />Site Mitigation Well Permit Application <br />