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i <br /> i <br /> San Joaquin County Environmental Health Department <br /> WELL$ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR#: <br /> LICEN D 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 Pro ons Code an my license is in full force and effect. <br /> Contractor Name:V&W Drilling F <br /> License#: 720,904 C-57 -Expiration Date: 4/30/2022 <br /> Signature: Title: President/CEO <br /> Print Name: Karli R. Stroing KN D te: 8/31/21 <br /> WORKERS' COMPENSATION DEC ARATION <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 /> ® 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 /> 1 certify that in the performance of the wo for w ich this erm Is issued, I shall not employ any person in <br /> any manner so as to become subject t the wo kers'c mpen atibn law of California, and agree that if I <br /> should becomes bje t to Irkers"co pensation pro isions f Section 3700 of the Labor Code, I shall <br /> rth 'I c rJ;y wit thos provisions. <br /> Signature: <br /> tA <br /> Print Name: Karli R. Stroing <br /> WARNING: FAILURE TO SECURE WOR ' 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 /> h Karli R.Stroing ,hereby or a Wallace-Kuhl ociates <br /> Nem Aul 011tetl NepfeeenullW nnl Nem ut a tl Ap.nl <br /> to sign this San Joaquin Co my well&; oring Per it Ap icatiion on my,;Zalf, understand this <br /> authorization is valid for one ea a d It to the k n dated on the front, age of this application. <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />