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, hereby authoriz <br />horped Apo <br />San Joaquin County Environmenta Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 'ta IDDC AO ti PERMIT SR #: <br />LICENSED CO MCA4 ItITECLARATION <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*: 72 04 A piration Date: 4/30/2022 <br />Signature: le: President <br />Print Name: Karli Renae troing D te: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declar tions: (check one) <br />I have and will maintain a certificate of consent to seIf-iiisure for workers' compensation, as <br />provided for by Section 3700 of the Labor Code, for th performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insuran e, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which thi "eirriit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: State Fund Policy #: 9115022-20 <br />I certify that in the performance of the w or which this permit is issued, I shall not employ any person in <br />any manner so as to become subject o the workers'-sompensation law of California, and agree that if I <br />should become subject to orkers c mpensation pro\ isions of Section 3700 of the Labor Code, I shall <br />forth ith comply with,4hose provisions. <br />Exp. Date: 10/2 /2 022 <br /> <br />Signature. <br />Print Name: Karli Renae Stroing <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION C•VERAGE 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, INTERE T, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR C' DE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNI PERMIT A LICATION <br />Karli Renee Stroing <br />Name of C-57 Licensed A,,thonod R.presontative <br />to sign this San Joaquin County Well & Bor g Permit Application on my behalf. I under tarid this <br />authorization is valid for one year and i ite to the work p n. .dpn the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application