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SAN JOAQUIN COUNTY <br />1., COMMUNITY DEVELMWENT DEPARTMENT <br />1610 E HAZELTON AVE. STOWON. CA 95205 <br />rte'+ DEVELOPMENT SERVICES PHONE 12091 489.7120 <br />PLANNtxi PHONE 12091 4650120 <br />BU9.OWG PHONE: 12091463-3123 <br />NEIGH80RHOOD PRESERVATION PHONE, 12091 4657021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location 120 S- 57 /7 /'°�^� (4 <br />owner Phone No. Z�S 599 �ZG <br />Contractor, S�''10� Phone No.Vq-5Z<4'?653 License No. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project <br />completion, or <br />✓ 2. Submission of verification, e.g. load ticket, within 30 days of project <br />icompletion that one of the following materials was placed, in the excavation in <br />12" lifter <br />A. Pea gravel - smooth, rounded material not more than one-half (1/2) <br />Inch in diameter. <br />_ B. Crushed rock - self -compacting material not more than three-quarters <br />(3/4) inch in cross sectional measurement. (Use of crushed rock <br />will not be permitted for backfill if contact will be made between <br />the backfill material and tanke/pipes made of poly resin glass or <br />similar materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br />of project completion, or submission of verification that the select material described above <br />will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br />that the entire excavation will be backfilled and compacted to insure compliance with the <br />Uniform Building Code Appendix Chapter 70. <br />Name (Print) <br />tle(P* r n ) <br />(te{ <br />Signature <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />