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, hereby authorize ce-Kuhl & Associates I, Karli R. Stroing <br />Name of C-87 Licensed Authonatml Rapnosentsfive <br />to sign this San Joaquin County Well <br />authorization is valid for one yeAr and-is I <br />Print Name of /Uniformed Agent <br />& Boring Permit Application on my behalf. I understand this <br />ed to the,work plan dated on the front page of this application. <br />El-ID 29-01 6-23-2015 Site Mitigation Well Permit Application <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />21001 & 21187 N Elliott Rd, Stockton, CA JOB ADDRESS: PERMIT SR #: <br /> <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 Expiration Date: 4/30/2022 <br /> <br />Signature: <br />Print Name: Karli R. Stroing <br /> <br />Title: President/CEO <br /> <br />Date: 9/1/21 <br /> <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 />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subj9ct-to the workers' cox inVeiisation law of California, and agree that if I <br />should become subject to worker' conipensation provisions'of Section 3700 of the Labor Code, I shall <br />orthwifh comply with those provisions. <br />Signature: <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 />State Fund Carrier: Policy #:9115022-20 Exp. Date: 10/2 /2021