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San Joaquin County Environmental Health Department <br /> WELL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 5756 Pacific Avenue, Stockton Califomia 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: Sierra Tech. Services, Inc. <br /> License#: C- 9r 309 Expiration Date: 31,31,-2 Cit� <br /> r <br /> Signature: Title: L12fA; j"r- <br /> Print Name: ji d�1j�r -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 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 /> 0 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:�f�,CCI 0 Ills j yt� Policy7J3T11 Exp. Date: <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' compensation law of California, and agree that if I <br /> should become subject to workersco pensation provisions of Section 3700 of the Labor Code, I shall <br /> ,.,forth ith comply with those provisions. <br /> Signature: <br /> Print Name: _ <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, ATTORNEYS FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> l Paul White hereby authorize James Scott Seyfried <br /> cameOA htw . <br /> to sign this San Joaquin County Bo ' g Permit Application on my behalf,i understand this <br /> authorization is valid for one year a s limit to the work plan dated on the front page of this application. <br /> EHD 2301 6-23-2015 Site Mitigation Well Permit Application <br />