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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: _ l $� 1 E C4� fA( eeW v T • 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, <br />License #. 720904 <br />Signature: <br />Print Name: Karli Renae Stroing <br />Expiration Date: 4/30/202 <br />Title: President <br />Date: <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 />a 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: 10/2/2022 <br />I certify that in the performance of the work for wjli this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the orker ' compe'ns ion law of California, and agree that if I <br />should become subject to workers' compen ation rovisions oflection 3700 of the Labor Code, I shall <br />;,-� ,-forthwith corXplywith those pr9disions. <br />Signature: <br />Print Name: Karli Renae Stroing t� / <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 CODE <br />1 Karli Renae Stroing , her y au orize <br />-oma orZaneetl <br />'p- <br />-lair.. - ---- e� o1 Who , , <br />to sign this San Joaquin County Well & Boring ermit pplication on m ehaIf. I unders and this <br />authorization is valid for o y r Is i ited to th wo Rlan dated on the front page of this application. <br />7-T <br />g roo s YdRepmmt. <br />EHn 29 016 23-2015 Site Mitigation Well Permit Application <br />