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License #: 720 04 Expiration Date: 4/30/2022 <br />Signature: <br />Print Name: Karli Renae Stroing <br />Title: i Pres'd en <br />I <br />Date: il Il 2 I <br />horded Representative <br />JOB ADDRESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />Win CA 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 />Division 3 of the California Business and Professions Code and my license is in full force and effect. <br />Contractor Name: V & W Drilling, <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 #: 9115022-20 <br />I certify that in the performance of the work for which this pkrmit is issued, I shall not employ any person in <br />workers' comp nsation law of California, and agree that if I <br />sation provisiorjs of Section 3700 of the Labor Code, I shall <br />mr4y withthosé provisions. <br />si IN? 1/r— <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 C-57 SIG <br />Karli Renae Stroing , hereb authorize Name of CJ7 Lk.nnd Authorized Representative <br />to sign this San Joaquin County Wel & Bonn • Permit Application o my behalf. I understand this <br />authorization is valid for oreyéaraqd islmited tot e work •Ian dated o the front page of this application. <br />VALtu of 6 <br />Exp. Date: 10/2/2022 <br />any manner so as to become subject t <br />should become s bject to workers' co <br />forthwi <br />Signature: <br /> 1\i'D <br />PERMIT APPLICATI N <br />Utta Lcl:c)./ec <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application