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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: L�� >' 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 /> kA <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V & W Drilling4Inc(--- <br /> License#: Inc( <br /> 720904 f 1 _—Expiration Date: 4/30/2020 <br /> Signature: I Title: President <br /> Print Name: Karli Renae Stroing G <br /> 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 work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to te workers' compensation law of California. and agree that if I <br /> should become subject to workers' compensation provisian of Section 3700 of the Labor Code, I shall <br /> orthwlth mply with thos�provisions. <br /> Signature: 1C i ' <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.-6 7 SIGNING PERMIT APPLICATION <br /> I Karli Renae Stroing _ <br /> ere' <br /> authorize <br /> tiama of C-Y,L,crosM AuthenzM Rcpmsmtabve not Narno o tbonzce Agent �— <br /> to sign this San Joaquin Coyne}+Well & Brmit Application on my behalf. I understand this <br /> authorization is valid for one yeaf arld is I'm tewrk plan dated on the front page of this application. <br /> 't <br /> alum o ,<cr, nz ' cPresrn bv< ---- <br /> 1 <br /> EHD 29-01 6-23-2015 Site Mitigation well Permit Application <br />