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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS. "J \1d'1 i A QO PERMIT SR #: <br />LICE[t5ED Cbf1TRACTORS 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 <br />License #: <br />Signature: <br />Print Name: Karli Renae <br />Expiration Date: 4/30/2022 <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 />0 provided for by Section 3700 of the Labor Code, for the' performance of the work for which this <br />permit is issued. <br />have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />14 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 Exp. Date: 10/2/2022 <br />I certify that in the performance of the for which this permit is issued, I shall not employ any person in <br />any manner so as to become sub <br />t to a worker ' pensation law of California, and agree that if I <br />should become subject to worker comp nsation rovi ions of Section 3700 of the Labor Code, I shall <br />�I fo hwith cgmply with those provisions. <br />Signature: u <br />Print Name: Karli Renae <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES iAND 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 />ER TH <br />I, Karli Renae Stroing he <br />IWd t uNe prur,btivo <br />to sign this San Joaquin County Well Boring <br />authorization is valid for one vdar aad is Ti ed to t <br />\pplication on y behalf. I understand this <br />plan dated ont e front page of this application. <br />t. <br />EHD 29-01 G23-2015 Site Mitigation Well Permit Application <br />