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r <br />SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E HAZELTON AVE, STOCKTON. CA 85205 <br />DEVELOPMENT SERVICES PHONE 1209) 468.3120 <br />PLANNING PHONE 12091 468-3120 <br />BUILDING PHONE (2091468-3123 <br />NEIGHBORHOOD PRESERVATION PHONE (2091 468.3021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location i!_liff.as7- /Fl-e-ae irw 57-- 7 -RAG/ &4 1l37'3iC <br />Owner G47 -y 6,r ICY Phone No. Zo y $3G • r/�/2 PJ <br />Contractor j()Ql/yA/� rUdiQtY✓.U�vGJ]Phone No. Z)?-< -75-X License No. G$%y'b/ <br />�62t13'C,�`Sf .fiYC. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />'F -. 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 />completion that one of the following materials was placed in the excavation in <br />12" lifts: <br />_ A. Pea gravel - smooth, rounded material not more than one-half (1/2) <br />inch in diameter. <br />�H. 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 />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 />* <br />* Shall be the responsible managing <br />agent. <br />,., 6/91-LC/BECERT.DOC <br />Name (Print) <br />oyee on the license or authorized <br />