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San Joaquin County Environmental Health Department <br />WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: u lE'► V I Oiaa—" PERMIT SR #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapti6r 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 Dri ing, Inc. <br />License #: 720 04 <br />Expiration Date: 4/30/2022 <br />Signature: Title: Presi en <br />Karli Renae roi g <br />Print Name: Date: <br />7 1,97 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following decla tions: (check one) <br />I have and will maintain a certificate of consent to self -I sure for workers' compensation, as <br />13 provided for by Section 3700 of the Labor Code, for th 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 arIIO: <br />Carrier: State Fund Policy #: 9115022-20 Exp. Date: 10/2/2022 <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become ect to the wo kers' compensation law of California, and agree that if I <br />should become subject to w rker ' compensat' n provisions of Section 3700 of the Labor Code, I shall <br />fo hwith comply with those provisions. <br />Signature: <br />Print Name: Karli Renae Stroing <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 C�DE <br />AUTHORIZATION FOR OTHER THAN C-57 SIG G PERMIT APPLICATION <br />I, Karli Renae Stroing <br />her y au orize J <br />t of Auth W1 <br />to sign this San Joaquin County Well & Boring rmit pplication o y behalf. I understand this <br />authorization is valid for on y r anTa liar l d to the ork pilan dated n the front page of this application. <br />EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />