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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />��11 t <br />ST <br />JOB ADDRESS: V �-'C PERMIT SR #: <br />ICENSED 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 #: <br />Signature: <br />Print Name: Karli Renae Stroing <br />Expiration Date: <br />WORKERS' COMPENSATION DECLARATION <br />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 />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 #: 9115022-18 Exp. Date: 10/2/2019 <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 thew 'kers compensation law of California, and agree that if I <br />should become subject to worker>' compens tion provisions of S on 3700 of the Labor Code, I shall <br />J � o hwith co ly vo those pro Isi ns. <br />Signature: <br />Print Name: Karli Renae Stroi <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 <br />I, Karli Renae Stroing ,hereby auth iter%���2�t/ <br />Name of C- icense <br />Ld .thorind ep—ent w. t fume tII t <br />to sign this San Joaquin C unty Well & Lring Perm' Application on my be f. I understand this <br />authorization is valid for on y r and ' imithe wo pla dated on the f ont age of this application. <br />nate of C Licen etho a Love <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />