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ECEIVED <br /> MAY 2 3 2013 <br /> San Joaquin County Environmental Health Department 7 NVIRONMENTAL HEJ LTH <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL D�Pl TlSFfiVICE <br /> JOB ADDRESS: 2811 E. Fremont Street, Stockton PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 /> License#: <br /> C57-720904 Exp Date: 4/30/2014 <br /> 5/14//13, V&W Drilling <br /> Date: ontractor: <br /> �y I <br /> Signature: { � � Title: President <br /> Print Name: Karli Str ng <br /> ORKE ' ' C0MPtNSATION 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 /> xx 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 Compensation Ins Fund Policy Number: 9026354-12 <br /> 1 certify that in the performance of the work for which this permit is issued all not employ any <br /> person in any manner so as to become subject to the workers' co psation Ia of California, <br /> and agree that if I should become subject to workers' comp"iorfp ovisions of Sec on 3700 of <br /> the Labor Code, I shall forthwith comply with thosl pr is 6nl. <br /> 10/1/2013 <br /> Exp. Date: Signature:, <br /> Karli ��o <br /> ing <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWIUL,AND SHAL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO`ME COST )IF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Karli Stroing (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Ray Kab1anow to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />