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.wa. � Z <br /> SAN JOAOUIN COUNTY <br /> �:! s�fs COMMUNITY DEVELOPMENT DEPARTMENT <br /> �� 1610 E HAZELTON AVE.STOCKTON.G 95206 <br /> DEVELOPMENT SERNCES PHONE 12091 466.3120 <br /> AANN910 PHONE 12091 460-3120 <br /> WADW PHONE(2091 46a 3123 . . <br /> NEGHBOM4000 PIIESEMATON ALONE 12091468-3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> 7 59 S gi��r>✓ u��u ��,� (If � <br /> Project Location ' `l"'`"�"� <br /> �Vhn �II()h Phone No. an9_ 9fC ylD� <br /> Owner nn,,,��/� 6 k, V <br /> Contractor <br /> t Phone No.�/�1 �3� License No. <br /> w S�"1G <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 /> ollowing materials was placed in the excavation in <br /> completion that one of the f <br /> 12" lifter <br /> A. Pea gravel - smooth, rounded ma <br /> terial not more than one-half (1/2) <br /> — inch in diameter. <br /> n three <br /> --- B (Crushed <br /> us einch rock <br /> in cross self_cosectional mmeasurem meaaterial not surement. <br /> more <br /> ofcrushed <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 /> s�:eimilar materials. ) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> cubic yards per 1000 gallon tank displacement and <br /> of project completion, or submission of verification that the select material described above <br /> will be placed at a minimum of Five (5) <br /> that the <br /> Bentire <br /> gexcavation <br /> Appendixwill <br /> Chapt backfilled and compacted to insure compliance with the <br /> Unif <br /> rm <br /> Code <br /> . r&zL <br /> a <br /> Name (Print) <br /> T le PfLnl <br /> S gnature <br /> * Shall be the responsible managillg employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />