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Application - Grading Building Permft
<br /> SAN JOAQUIN COUNTY CON PAO Y DEVELOPIIENT OEPARIlE1R
<br /> 1810 E.HAZELTON AVENUE,STOCKTON,CA.SMS
<br /> KIMM PHONE M"4"41=
<br /> REQUEST FOR INSPECTION PHONE 0"66&31"(24 HOUR RECORDER
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<br /> Technician• Cate:
<br /> Job-Oft Address: APN: -
<br /> Cross-Street: CNy: ZIP:
<br /> Precise Locall m
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<br /> Scop"WOE Place aud gradS 4100 yards of dirt on road
<br /> Dirt contaminated with less than 500 ppm. Diesel
<br /> Number of Cubic Yards to be moved: 0
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<br /> Nares: Frank C. Alegre Name:
<br /> Address: 5100 West Hwy 12- Address:
<br /> City: Lodi A womica city: state:
<br /> zip: 95242 ph:(209 334-2112 ; Ph:( )
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<br /> Lic.No: Company Name:Owner
<br /> Address: City: st: ZIP:
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<br /> Address: City: SL ZIP:
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<br /> }'-1NiE '!`"'' Exhftq On-She Well: New On-Site Well: Public:
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<br /> Exiethrg Septic System: New Septic System: Public:
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<br /> No Change: New On-Site System: Public:
<br /> New Curb-Gutter
<br /> pf :, • Exiss"Dripeway: New With Curb-Gutter: Without
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<br /> ern ui must submit the following with their application
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<br /> • A property talc statement or a,recorded deed
<br /> • A completed and signed*O mer-BuIlder Verification'form
<br /> • A completed'Authorization for Application'form If other than the owner applies.
<br /> Contractors must submit the following with their application:
<br /> Current license numbers and a worker's compensation Insurance certification (this is not necessary ff this information Is already
<br /> on file with the Department)
<br /> • A waiver form ff the contractor Is not subject to worker's compensation laws
<br /> • A completed'Authorized to Sign'form It other than the contractor applies (this is not necessary If this information is already on
<br /> file with the Department).
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