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I' <br />SAN JOAOUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />1010 E HAMTON AVE. STOCNION, CA 95205 <br />OEVELOPWW SERVICES PHONE (209) 4664120 <br />NNI46443 PHONE (2091 100-3120 <br />WXOM PHONE (209) 460.3123 <br />Nffi @W HOOD PAESOI AWN PHONE: R09) 160-7021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location <br />Owner THERESA M. MMLER <br />75 L. ALPINE AVENUE, STOCKTON, CA 95204 <br />Phone No. (408) 395 3991 <br />Contractor JAMES J. HOBLITZELL phone No. (209) 943 7793 License No. 365234 <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 />X 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" lifter <br />X 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 crone sectional measurement. (Use of crushed rock <br />will not be permit`.ed 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 />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 />* JAMES J. HOBLITZELL <br />Name (Print) <br />CONTRACTOR <br />Title (Print) <br />gllature <br />* Shall be the responsible managing employee on the or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />15 <br />