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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICA11ON SUPPLEMENTAL <br />JOB ADDRESS: d,--)4� Ll �,J ''al V f V hq PERMIT SR #: <br />l � � <br />LICENSED CONT&AARS dECLARATION <br />I hereby affirm that I am licensed under the provisions of Cha <br />Division 3 of the California Business and Professions Code <br />Contractor Name: V & W j2rffffng, Inc. <br />License #: 720 <br />Signature: <br />Print Name: Karli Renae <br />b <br />9 (commencing with Section 7000) of <br />my license is in full force and effect. <br />n Date: 4/30/2022 <br />Title: President <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 />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 I his permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: State Fund Poll #: 911502240 Exp. Date: 10/2/2022 <br />1 certify that in the performance of the work for which his permit i issued, I shall not employ any person in <br />any manner so as to become subject to the worke ' compensation law of California, and agree that if I <br />should become subject to wort ers' compensatio • <br />or <br />of Section 3700 of the Labor Code, I shall <br />� fprthwith comply with those provisions. <br />9 <br />Si nature:,K)�,0 12 <br />Print Name: Karli Renae Strew q <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATIONCOVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIESIAND 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 />AUTHORIZATION FOR OTHER T <br />I, Karli Renae Stroing <br />Na— of C-57 Licensed Autherizod Representatl- <br />to sign this San JoaqVn(;unty WeIG Bo <br />authorization is valid for or 4 t liited <br />�i, <br />, hereby adthorize <br />Perm it'Application on my behalf. understand this <br />ie w�jArk plan dated on the front age of this application. <br />-1—Yl'. , I YJ <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />