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San J a4uin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SIR#: <br /> Feu <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, c. <br /> License#. 720 04 <br /> Expiration Date: 4/30/2022 <br /> Signature: Title: President <br /> Print Name: Karli Renae Stroing Date: <br /> WORKE COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perju 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 /> E3 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: 10/2/2021 <br /> 1 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 subject to the wortpistrt <br /> compensation law of California, and agree that if I <br /> should become subject to workers' ensativisions of Section 3700 of the Labor Code, I shall <br /> j fortwith comp those provisions. <br /> Signature: VW <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 CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Karli Renae Stroing eby authorize� [A 14 I14- k <br /> Name of C-57 Licensed Authorized Representative not Name of Aut nz A nt <br /> M4 <br /> to sign this San Joaquin County Well& oring Permit App' on on my behalf.I understand this <br /> authorization is valid for one 'ear and limit d to t e work pl n da d on the front page of this application. <br /> tgrud re o 7 tensed Authorized RepNsqhfative <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />