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1 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �,� � '1 PERMIT SR #: <br /> ofr <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 Drilling. Inc. <br /> License #: 72 04 / Expiration Date. 4/30/2020 <br /> Signature: �, �1� Title: Presi ent <br /> Print Name. Karli Renae Stroing Date <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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 Wb_rk for which this permit is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation law of California. and agree that if I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> k�DSignature: _ <br /> Print Name: Karli Renae Stroing <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 APPLICATION <br /> Karli Renae Stroing hereby authorize i <br /> d RepeA„e M C�57 L�censetl Au,horm — <br /> ---- - ---- <br /> � Pi,tl til iic I F„tn it r,h..ilr iii ' <br /> to sign this San Joaquin Cqunty WeII4 Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one e r and its li ited to'the work plan dated on the front page of this application. <br /> iynuun l cenu spm"nw <br /> EHD ?9 23-?0!5 Site Mitigation Well Permit Application <br />