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San J�aquln County Environmental <br />WELL & BORING PERMIT APPLICA' <br />JOB ADDRESS: a 6 (A 6 . Kai <br />Ith Department <br />J SUPPLEMENTAL <br />PERMIT SR #: <br />VAeu x <br />CENSED 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 #. 72 <br />Signature: J /V V <br />Print Name: Karli Renae Stroinq <br />ration Date: 4/30/2022 <br />President <br />WORKE S' COMPENSATION D C ARATION <br />I hereby affirm under penalty of perju one of the following declara ions: (check one) <br />I have and will maintain a certificate of consent to self-ir sure for workers' compensation, as <br />O 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 />I certify that in the performance of the <br />any manner so as to become subje <br />should become subject to workers' <br />. i o_ 0 for <br />Signature:�" Vw } V l <br />Print Name: Karli Renae Stro <br />work for which this permit is issued, I shall not employ any person in <br />:t to thewor rs' compensation law of California, and agree that if I <br />ensati <br />rprovisions of Section 3700 of the Labor Code, I shall <br />fwith comp ith those Drov sions. <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 OFCOMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CC DE <br />7 <br />1, Karli Renae Stroing <br />to sign this San Joaquin County Well & <br />authorization is valid for one year and is, liml <br />-IAN C-57 SIGN <br />1117 by authorize <br />•ing Permit AppAM <br />to t!e work pl n d <br />PLI <br />in on my behalf. I understand this <br />J on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />