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12/03/2003 <br />Project <br />13:10 20946717'8 <br />AGE STOCKTON <br />BACKFILL EXCAVA77ON CM�TIFICATE <br />PAGE 06/09 <br />. - - — Phone No. <br />Contractor--Q(PS.1�5i [Cl1 _ x n 1 <br />Phone No.C L cense No. <br />NbICATE METHOD OF BACIMLL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />X2. Submission of verification, e.g., load ricket, within 30 days of project completion that one of the following materials was <br />placed in the excavation in 12" lifts: <br />XA. Pea gravel -smooth, rounded material nor more than one-half (1/2) inch in diameter <br />B. Crushed rock-self-cornpacdng material not more than tbree-9Uaren (3/4) inch in cross sectional <br />measurement. (Use of crushed rock will not be permitted for backfill if cotuaet will be made between the <br />backfz11 material and ranks/pipes made of poly resin glass or similar materials.) <br />DECLARATION <br />1 berebY certify that a Soil Engineer's Com action Report will be submitted within 30 sof <br />verifrcadon that the select material described abovewillbe placed az a mat Mum of (ive (5�care� cbic ompletion, <br />per l0pp submission of <br />displacement and that the entire excavation will be backfilled and compacted to iusure compliance with the Uttifarat Building Code <br />Appendu Chanter 70. <br />acne <br />,e <br />42— <br />�tgaanite <br />Shall be the responsible managing employee on the license or authorized agent, <br />