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i <br />San .Joaquin County Environ <br />WELL $ BORING PERMIT API <br />JOB ADDRESS: 1717 Sanguinel Lane, Stockton, CA <br />LICEN <br />I Health Department <br />,TION SUPPLEMENTAL <br />TORS OE <br />I hereby affirm that I am licensed under the provisions of Chz <br />Division 3 of the California Business and Professions Code <br />Contractor Name: V&W Drilling !" <br />License #: 7 0904 ( -57) <br />t <br />Signature: <br />Print Name: Karli R. Stroi <br />I hereby affirm under penalty of perjury one of the following declar <br />I have and will maintain a certificate of consent to self - <br />provided for by Section 3700 of the Labor Code, for th, <br />permit is issued. <br />I have and will maintain workers' compensation insurai <br />® Labor Code, for the performance of the work for which <br />compensation insurance carrier and policy numbers ar <br />Carrier: State Fund Policy #: 911502 <br />I certify that in the performance <br />any manner so as to becorr� <br />should become sybject to yboi <br />Signature: Aa/ <br />Print Name: Karli R. <br />e work fo ichthis permit i <br />:ct to th, or ers' compensa <br />comp�nsati provisions of <br />00 with compi with those pro <br />PERMIT SR #: <br />9 (commencing with Section 7000) of <br />my license is in full force and effect. <br />tion Date: 4/30/2022 <br />President/CEO <br />7/19/21 <br />tions: (check one) <br />sure for workers' compensation, as <br />performance of the work for which this <br />as required by Section 3700 of the <br />permit is issued. My workers' <br />Exp. Date: 10/2/2021 <br />issued, I shall not employ any person in <br />on law of California, and agree that if I <br />ection 3700 of the Labor Code, I shall <br />sions. <br />WARNING: FAILURE TO SECURE4WO(RKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYEk 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 />to sign this San Joaquin <br />authorization Is valid for one) <br />EHD 29-016-23-2015 <br />_ , ereby <br />BoriPerr <br />:ed to t w <br />(lace -Kuhl & Associates <br />t mol VMotrsW gtnt <br />n my behalf. I understand this <br />on the front page of this application. <br />Site Mitigation Well Permit Application <br />