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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />Southeast corner South Main Street & E. Atherton Drive <br />JOB ADDRESS: Manteca, CA [APN's 224-040-09, and 224-040-041 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. <br />License #: <br />Signature: <br />Print Name: Karli Renae Stroing <br />Expiration Date: <br />Date: 09/13/21 <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 />C3 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 />1A 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 <br />Policy #: 9115022-20 <br />Exp. Date: 10/2/2021 <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 subject to the workers' copeensation law of California, and agree that if I <br />should become subject to workers' compensation provisio s of Section 3700 of the Labor Code, I shall <br />Signature: <br />Print Name: Karli Renae Strol <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 />AMfi: IR <br />I, Karli Renae Stroing , hereby authorize 14 11Vr L,v 1 <br />Name o icenuo Authorind epresanah- tint lme of oruiiAgent <br />to sign this San Joaquin County Well & B ring Permit ppli ation o my ehalf. I understand this <br />authorization is valid for one ySe�And imit�d to the work play} dazed oo the ront page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />