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JOB ADDRESS: <br />San Joaquin County EnvironmentallHealth Department <br />WELL & BiORING PERMIT APPLICATION SUPPLEMENTAL <br />I <br />LICENSED CONTRACTORS <br />I hereby affirm that I am licensed under the provisions of Che <br />Division 3 of the California Business and Professions Code <br />Contractor Name: V & W Drilling, <br />License ##: 7 <br />S4rtature: <br />Print Name: Karli Renae Stroing <br />PERMIT SR #: <br />r 9 (commencing with Section 7000) of <br />my license is in full force and effect. <br />n Date: 4/30/2022 <br />President <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 work for which this permit islissued, I shall not employ any person in <br />any manner so as to become subject to the wor rs' compensation law of California, and agree that if I <br />should become subject to workers' eempensatpith <br />provisions of Section 3700 of the Labor Code, I shall <br />forthwith comp those provisions. <br />Signature: <br />Print Name: Karli Renae Stroinl <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES SAND 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 CODE <br />I, Karli Renae Stroing <br />to sign this San Joaquin County Well & <br />authorization is valid for one Vear and is liml <br />authorize <br />ring Phrmit . <br />to tPe work <br />APPLICATION <br />(,NdO( b � L- <br />on my behalf. I understand this <br />on the front page of this application. <br />EHD 29-01 6-23-2015 1 Site Mitigation Well Permit Application <br />