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Expiration Date: 4/30/2022 Title: President License #: 72 Signature: 7 Licono.t op asontabve Sign EHD 29-01 6-23•2.5 Site Mitigation Well Permit Application San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: 0' (Cal • 'MA (koi tyt PERMIT SR #: W\ LICENSED CONTRACTORS DECLARATION I hereby affi'm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. Contractor Name: V & 'A/ ' , Inc. Print Name: Karl' Reiae Stro Date: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensaticn ins:Jrance carrier and policy numbers are: Carrier: State Fund Policy it: 9115022-20 Exp. Date: 10/2/2022 iify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become sub - - o the workers' compensation law of California, and agree that if I should bei-i-ie subject to work s coTpensation ovi •ons of Section 3700 of the Labor Code, I shall hwith comply , ith th se provisions. / Signature: Print Name: Kas:ii Renee Stroing WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITIOK TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION , n eby auth rize AL Vj,1 ame of uIt,o, zed Agent to sign thls San Joaqu;;.. Coun,:y Well Boring emit Application onimy beh If. I understand this authorization Is valid for one ar arts is Ii ed to the or plan cated on the fr t page of this application. Karli Re,•.ae Strcing Name AuthorizZilop.z.;arnative