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IOC AfM�RESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICA ION SUPPLEMENTAL <br />(C <br />I hereby affiirm that I am licensed under the provisions of Chap <br />Division 3 of the California Business and Professions Code a <br />Contractor' Name: `� & W Drilling, <br />License 4: 720904 n <br />Print Name: Karli Renae Stroing <br />F�tl�lf 9" SR #; <br />9 (commencing with Section 7000) of <br />my license is in full force and effect, <br />irafiion bate: 4/30/2022 <br />President <br />I hereby affirm under penalty of perjuryi one of the following declarations: (ofaec:lc cane) <br />I have and will maintain a certificate of consent to self -'sure for workers' compensation, as <br />Q provided for by Section 37QO of the Labor Code, for the�performance of the work for which this <br />permit is issued. <br />I have and will maintain woi*ers' compensation insuran6e, as required by Section 3700 of the <br />01 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 />Qarrie67 <br />: State Fund <br />e talfcJ #: 911 <br />EnP. Date: 10/7 /2021 <br />I cer'iify thai in the pel iormance of the',work for which Phis permit isiissued, f shall not employ any person in <br />any manner so as to become subject to the wor rs' compensatron law of California, and agree that if I <br />should become subject to workers' c"ensati�ir�i provisions of Section 3700 of the Labor Code, I shall <br />forthwith compjy Wth those provisions. <br />Signature: /V VW 1,.v1 <br />1t <br />Print Name: E<arli Renae Str©in <br />W61RR11PlO: FAILURE TO <br />SECURE WORKERS' COMPENSATI®N CtjVERACaE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TD 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 />75 Mk <br />I, I<arli Renae Sfiroing <br />to sign this San Joaquin County Well & <br />authorization is valid for one 1r~ear.and is liml <br />authorize <br />ring PrrF•tnit App on on my behalf. I understand this <br />to t�te work pl n da ' don the front page of this application. <br />EHD 29-01 6 -?_3-2015 I Site Miti ation Well Permit <br />g Application <br />