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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: "" 1� Cl� V1 PERMIT SR #: <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, I(l— <br /> License#: <br /> c7�, <br /> 7209P4 Expiration Date: 4/30/2020 <br /> Signature: ' 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 performanceof the w .",kfor which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject o the�orkers' cm ensation law of California, and agree that if I <br /> should becomqect to workers' co pens;tion pro, isio s of Section 3700 of the Labor Code, I shall <br /> forthwi comply with ithop provisions. <br /> t � r <br /> Signature: <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 APPLICAT ON <br /> MdKarli Renae Stroing I here y au horize <br /> N—vo Icons uthorized Representauvo P nt a n oriaid goat <br /> to sign this San Joaquin County W�ll &Boring it Application on)y behalf. I understand this <br /> authorization is valid for one ye r d i li ited to th wo k plan dated ona front page of this application. <br /> r r � <br /> qnN of CLiton Aut need opresmtauvo <br /> EHD 29-01 6-23-2015 Site Mitigation well Permit Application <br />