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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> JOB ADDRESS : 717 W . Atherton Drive , Manteca , CA 95337 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 , Inc . <br /> License # : 720PO4 Expiration Date : 4/30/2022 <br /> Signature : Title : President <br /> Print Name : Karli Renae Stroing Date : 05/03/21 <br /> WORKERS ' COMPENSATION DECLARATION <br /> 1 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 Exp . Date : 1012/2021 <br /> I certify that in the performance of the work for which this permit is issued , I shall not employ any person in <br /> any manner so as to become subject to the workers' co nsation law of California , and agree that if I <br /> should become subject to workers' compensation provisio s of Section 3700 of the Labor Code , I shall <br /> forthwit mply with thos provisions . <br /> 1 <br /> Signature : AZI LlV <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 $ 10010009 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 PERMT APPLICATION <br /> lKarli Renae Stroing , hereby authorize �,� . <br /> Name tensa Authorized Representative M of ' AQtM <br /> to sign this San Joaquin County Well & B ring Permit ppli ation o my ehalf. l understand this <br /> authorization is valid for one a nd imi d to the work pl dged o the ront page of this application . <br /> Stgnatun di C rt"d Aut= <br /> sentstiw <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />