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SAN JOAQUIN COUNTY <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> IBM E. HAZELTON AVE.STOCKION,CA 85205 <br /> + kj1 DEVELOPMENT SERVICES PHONE:12091 465.3120 <br /> PLANNING PHONES 12091 468.3120 <br /> BUILDING PHONE:{2091 468-3123 <br /> NEIGHBORHOOD PRESE11VA410N PHONE: (2091 460.3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location t5 r <br /> Owner����I��r�%�- Phone No. <br /> contractor t� �' -;.`. 1 fir, Phone No. �_ License No.-�< 'i/C1 <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 /> �r , <br /> 2. Submission of verification, e.g. load ticket, within 30 days of project <br /> completion that one of the following materials was placed in the excavation In <br /> 12" lifts,; <br /> 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 tanks/pipes made of poly resin glass or <br /> similar materials. ) <br /> DECLhRATYON <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 /> �y <br /> T le,, <br /> grits ui e <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />