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San Joaquin County EnvironmentalHealth Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: \(XL I rin <br />HERMIT SR #: <br />LICENSE ) ICON I-RACTORS 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, lyre, n <br />License #: <br />Signature: <br />Print Name: Karli Renae <br />Expiration Date: 4/30/2022 <br />Title: Pres' en <br />_ Date: I l I I <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 />17 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 />Exp. Date: 10/2/2022 <br />I certify that in the performance of the work for which this rmit is issued, I shall not employ any person in <br />any manner so as to become subject t workers' comp nsation, law of California, and agree that if I <br />should become subject to workers'co pe cation provisio of Section 3700 of the Labor Code, I shall <br />fortlwi mply with1thos6 provisions. <br />Signature: <br />Print Name: Karli Renae <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 />I, Karli Renae Stroing hereb authorize <br />m,.enm.... .pn..nun.e <br />to sign this San Joaquin C unty Well & Borin Permit Applice <br />authorization is valid for orhe yra t a work plan d. <br />my behalf. I understand this <br />the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit <br />9 Application <br />