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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR #: <br /> L L/ <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 Dril . Inc. <br /> d== <br /> License #: 720994 Expiration Date: 4/30/2020 <br /> Signature: ! # <br /> 9 � V Title: President <br /> Print Name: Karli Renae Stroing Date: " J <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 /> I 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 become5-ubject to the orkers' compensation law of California, and agree that if I <br /> should become subject to vYorkers' compens ion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith com ly with those provisions. <br /> Signature: <br /> Print Name: Karli Renae Sfroin <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 PERIVILT APPLICATION <br /> I Karli Renae Stroing hereby a thorizeT <br /> Name of C37 Uemsetl AulMrintl Represontauve nNto sign this San Joaquin County Well Boring ermit Applicay behalf. I understand this <br /> authorization is valid for one y r an is i ited to t work plan de front page of this application. <br /> n of C-d7 stl A R pnanu ve <br /> E H D 2 9-01 6-23-2015 Site Mitigation well Permit Application <br />