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San Joaquin County EnvironmentalII Health Department <br />WELL &�ORING PERMIT APPLICAVION SUPPLEMENTAL <br />JOB ADDRESS: _ 1700 Union Road, Manteca, CA 95336 PERMIT SR #: <br />CENSED CONTRACTO <br />I hereby affirm that I am licensed under the provisions of Cha <br />Division 3 of the California Busines§,ai4 Professions Code <br />Contractor Name: V&W Drilling <br />License #: , 7?0904 (05-6T, <br />Signature: <br />Print Name: Karli R. Stro <br />I hereby affirm under penalty of perjury one of the following declarz <br />I have and will maintain a certificate of consent to self -ii <br />E provided for by Section 3700 of the Labor Code, for the <br />permit is issued. <br />I have and will maintain workers' compensation insuran <br />® Labor Code, for the performance of the work for which t <br />compensation insurance carrier and policy numbers are <br />Carrier: State Fund p16fi�y #: _9115022 <br />I certify that in the performance of the work <br />any manner so as to become subject to tt <br />should become subject to wo;keKs' comoe <br />Signature: !TA& �&u <br />Print Name: Karli R. Stroin <br />9;(commencing with Section 7000) of <br />my license is in full force and effect. <br />on Date: 4/30/2022 <br />President/CEO <br />11/29/21 <br />is: (check one) <br />re for workers' compensation, as <br />rformance of the work for which this <br />, as required by Section 3700 of the <br />;',permit is issued. My workers' <br />Z Exp. Date: �i� <br />h this permit is issued, I shall not employ any person i <br />rs' compensati n law of California, and agree that if I <br />provisions of Section 3700 of the Labor Code, I shall <br />with those Provisions. <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 CIE <br />I, Karli Ra 6trolnq , hereby au <br />—arm ,�-s�2�r��:.a <br />to sign this San Joaquin ounty W II & oring Permit' <br />authorization Is valid for orle�ar Ind I ite� to the work <br />EHD 29-016-23-2015 <br />ii, Associates <br />on my behalf. I understand this <br />on the front page of this application. <br />Site Mitigation Well Permit Application <br />