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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />--a) Vn fmn elixirs) JOB ADDRESS: P,—RMIT SR #: <br />Cu <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed und er the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the California Busin SS and Professions Code and my license is in full force and effect. <br />Contractor Name: V & W Drilling, Inc. <br />License #: 709O4 Expiration Date: 4/30/2022 <br />Signature: <br />Print Name: Karli Renae oing <br /> <br />Title: President <br /> <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 />0 <br /> <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 Exp. Date: 10/2/2022 <br /> <br />I certify that in the performance of the work fo,j.wh,ch this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the wor rs' compensation law of California, and agree that if I <br />should become subject to • ers' compensatio provisions of Section 3700 of the Labor Code, I shall <br />f hwith compl with those provisions. <br />Signature: <br />Print Name: Karli Renae Stro <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 />\x\ <br />Karli Renae Stroing • <br />Name of C.57 Lleansod Autherzzod Representative. <br />to sign this San Joaquin ounty W I & Bori <br />authorization is valid for o e ear nd I I mited t <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT A7LIC TIO <br />ereb auorize <br />g Permit Ap ication o my behalf. I understand this <br />th wolt playi dated on the front page of this application. <br />EHD 29-01 6-23-2016 Site Mitigation Well Permit Application