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San Joaquin County Environmental Health Department <br /> WELL&BiORING PERMIT APPLICA ION SUPPLEMENTAL <br /> i <br /> JOB ADDRESS: �' 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: V&W Drilling, hc. <br /> License#: 720 04 <br /> Expiration Date: 4/30l2022 <br /> s4riature: ' ��I ' <br /> Title: President <br /> Print Name: Karli Renae Stroing D te: <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 iperformanceof 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 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'eempensati provisions of Section 3700 of the Labor Code, I shall <br /> h 1 fort with comp yivith those provisions. <br /> Signature:AKarli <br /> Print Name: enae Stroing <br /> I <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES JAND 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 C9DE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Karli Renae Stroing eb authorize I` � <br /> 11_ma f C-57 L c—n d Art11—f[,d •pmx tativc Y ,nt — A.11 rlt A nl <br /> to sign this San Joaquin County Well& oring Pbrmit App' on on my behalf.I understand this <br /> authorization is valid for one ear and limit d to <br /> a work pl n da don the front page of this application. <br /> lgnnulco ensed AulhoAtoE ep Utire <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />