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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> t 1 <br /> JOB ADDRESS: �r `� )6ba-0PERMITSR #: <br /> LIVNSED 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, nc. <br /> License#: 720 04 Expiration Date: 4/30!2020 <br /> .. <br /> Signature: Title: President <br /> Print Name: Karli Renae Stroing (]ate <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 work which this perfnit is issued. I shall not employ any person in <br /> any manner so as to become subject to the orkers' compensation law of California. and agree that if I <br /> should become subject to wo ers' compensation provisioof Section 3700 of the Labor Code, I shall <br /> forthwith comply with thos�provisions. <br /> Signature: V4, <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 1 <br /> i / <br /> 1 Karla Renae: Stroing _ hereby autktorize L t <br /> Narni�otof C 57 licen sed Authonme Repms�nlanvr -- Uq,.nti,tfi0Authw;fe.d rnfto sign this San Joaquin Co my Well &. oring Permit Application on mX behalf. derstand this <br /> authorization is valid for on ye an s li it d to4o th workplan dated on tht front page of this application. <br /> If - <br /> qn o tcenae eptasen w _ <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />