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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 1341 West Robin hood Drive, Stockton, CA 9527 PERMIT SR #: <br />LICENSED CON <br />I hereby affirm that I am licensed under the provisions of Cha <br />Division 3 of the California Busines4.ari4 Professions Code <br />Contractor Name: V&W Drilling <br />License #: , 7?0904 <br />Signature: <br />Print Name: Karli R. <br />I hereby affirm under penalty of perjury one of the following declara <br />I have and will maintain a certificate of consent to self-ir <br />E provided for by Section 3700 of the Labor Code, for the <br />permit is issued. <br />I have and will maintain workers' compensation insuran <br />0 Labor Code, for the performance of the work for which t <br />compensation insurance carrier and policy numbers are <br />State Fund <br />Carrier:. ppj�y #; 9115022 <br />TI <br />9 (commencing with Section 7000) of <br />y license is in full force and effect. <br />iration Date: 4/30/2022 <br />President/CEO <br />11/29/21 <br />(check one) <br />for workers' compensation, as <br />rmance of the work for which this <br />as required by Section 3700 of the <br />is permit is issued. My workers' <br />?4 Exp. Date: <br />certify that in the performance of the work f whi h this permit is issued, I shall not employ an <br />p p y y person i <br />any manner so as to become subject to the work rs' compensati n law of California, and agree that if <br />should become sl�bject to woyke�s' compe satio provisions of �ection 3700 of the Labor Code, I shall <br />J h� f6jhwith c mply with those provioions. <br />Signature: <br />Print Name: Karli R. <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 CC DE <br />h Karli R. Stroing <br />-F�s7'CK.�,b�i .�iT,onzc��rea Tor- <br />to sign this San Joaquinbounty <br />authorization is valid for one v'ear ani <br />, hereby authgrke Wallace -Kuhl & Associates <br />& Boring Permit Appli ti n on my behalf. I understand this <br />M4 to 11 <br />the work pla kated on the front page of this application. <br />EHD 29-016-23-2015 1 Site Mitigation Well Permit Application <br />