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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1245 W Charter Way, Stockton <br /> PERIMIT SR# <br /> LICENSE CONTRACTORS DECLARATION (LCD) <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 Bus ness and Professions Code and my license is in full force and effect. <br /> License#: C57-720904 <br /> Exp Date: <br /> Date: ConV&W Drilling <br /> Signature: Title: Cn <br /> Print Name: Karli Str 4AK i tra tor: <br /> IN RKERS'COMPENSATION DECLARATIDN <br /> I hereby affirm under penalty of erjury one of the following declarations: (check one) <br /> —I have and will maintai i a certificate of consent to self-Insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> X <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 arrier and policy numbers are: <br /> Carrier: State Funi <br /> Policy Nu 9,026354-13 <br /> 1 certify that in the performance of the work for which this p mft is issued, hall not empl y any <br /> person in any manner so as to become subject to the work s' compensati n law of Cal'ornia, <br /> and agree that if I should become subject to workers'comperes an provisio s of Section 700 of <br /> the Labor Code, I shall fo hwith comply with those rovi ions. <br /> Exp.Date: 10/1/2014 Signature: <br /> Print Name: Karli SLroin <br /> WARNING;FAILURE TO SECURE 44411y11ORKE S'C MPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES'pNo CI IL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AN ,DAM Es AS PROVID OR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZAT P THER T C-57 SIGNING PERMIT APPLICATION <br /> Karli Stroing \ / <br /> U (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) R ld x 1a ; to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I un tan this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EH02MI 05109112 <br /> WELLPERMITAPP <br />