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r <br /> San Joaquin County Environmental Health Department <br /> 41'I/ELL& BORING PERMIT APPLICATION SUPPLEMENTAL, <br /> JOB ADDRESS: I�lG �Y PERMIT SR #: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapt r 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, In . <br /> Lcense#: 720 04 <br /> E�Cpiration Date: 4/30/2022 <br /> Signature:_ Til le: President <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 /> 13 provided for by Section 3700 of the Labor Code, for the <br /> performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insuranIce, 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 ar : <br /> Carrier: State Fund _ policy#: 9115022- 0 Exp. Date: 10/2/2021 <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 the workers' compensation law of California, and agree that if I <br /> should become subject to workers' compensation proviOpns of Section 3700 of the Labor Code, I shall <br /> forthwith,6orhply with those provisions. <br /> Signature: <br /> Print Name:"Karli Renae Stroing <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER 1(O 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 APPL.ICAT ON <br /> 1, Karli Renae Stroing <br /> hereby authorize <br /> Name C- Lltense ulhpnrnd eprasentahv -- --- nt Nameo InpneM.gpf <br /> to sign this San Joaquin County Well& Boring Permit Appllcatlon n my behalf. I understand this <br /> authorization is valid for one ye ran is lim ted to the',work plan dad n the front page,of this application. <br /> tura nt -5 kens I *pyo <br /> i <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />