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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SIR #: <br /> .......... <br /> (TO A r <br /> Ll -N E' 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, Inc. <br /> License 7?9,904 Expiration Date: 4/30/2020 <br /> Signature:, Title: P.reqiden <br /> j <br /> Print Name: .,Karli Renae S ruing ......... 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 /> 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#: 9115022-1810/2/2019 <br /> Exp. Date.--- —......................... <br /> I certify that in the performance of the work for ti ch this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the ork rs' compensation law of California, and agree that if I <br /> should become subject to work ipen tion provisions ci-�Section 3700 of the Labor Code, I shall <br /> 's' co"' <br /> w h �ions. <br /> thwitl ot ly,with those Povi <br /> Signature- <br /> .............. <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 SIGNING,, ERMIT APPLICATION, <br /> 1, Karli Renae Stroing hereby atff*ize <br /> e <br /> h <br /> to sign this San Joaquin Coun?Well & Boring Per <br /> "r' It Application b <br /> on my ef. I understand this <br /> * <br /> authorization is valid for one n to the w rk pip dated on the fro page of this application. <br /> Zf-Vui '�Vp <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />