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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: p Jlr! C�� r � �`� PERMIT SR #: <br /> LICENSED � �� � C� <br /> ONTRAOTORS 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 DrtH4.ng. Inc. <br /> License#: 720904 Expiration Date: 4/30/2020 <br /> Signature: ; Title: President <br /> Print Name Karli Renae troi g 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 /> 13 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 /> 14 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 #: 9115022-19 Exp. Date: 10/2/2020 <br /> 1 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 become subject--Y the workersompensation law of California, and agree that if I <br /> should become subject to workers' compensation pr isions of Section 3700 of the Labor Code. I shall <br /> rt ith comply wit those provisions. <br /> Signature �� ✓ G) G' ' <br /> -- <br /> Print Name: Karli Renae Str' <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 <br /> 11APP (CATION <br /> Karli Renae StrOing hereby authorize I (�1� <br /> Name of C-57 Licensed Audio-ed Rep--t.1"'. Rnnl Name of Aullnn: Apen' <br /> to sign this San Joaquin County Well & Boring P mit pPlicatio on my behalf. I understand tdS <br /> authorization is valid for oXyrpd is Ii ited to the or plan date on the front page of this application. <br /> s aline oto .con Au zea Rep.esencanve <br /> EHD 29-01 6-23-2015 Site Mitigation well Permit Application <br />