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ot. ! SANJOAOUINCOUNTY�,,..�COMMUNITY DEVELOPMENT DEPARTMENT <br /> WIN1610 E IWIELTON AVE.STOCKTON.CA 95905 <br /> OEVF.tOrMEFn SErwfiE Mt"-.12091 166 31 20 <br /> Mmorio MK)TIE.8091 466:Ttm <br /> 0U4UN0 MIDTIE:12091 4660123 <br /> NEKi110OT0KM MIESEITVA110N M"IE,12091 4663021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 714 N. Filbert St. Stockton, CA 99966 <br /> Owner Ramsey Real Estate Development Phone No. (209)466-8733 <br /> CotiLrar-Lor Jim Thorpe Oil, Inc. phone No. (209)368-6175 License No. 495699 <br /> INDICATE HETROD or BACKFILL QUALITY ASSURANCE <br /> 1. Submisnlon 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" llftaf <br /> -�G- A. Pea gravel - smooth, rounded material not more than one-half (1/1I <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 permitted for backfill if contact will be made between 1 <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 /> Jniform Building Code Appendix chapter 70. <br /> * Jim Thorpe Oil, Inc. <br /> Name (Print) <br /> Contractor <br /> A - <br /> s gnature <br /> F Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> i/91-LC/13ECERT.DOC <br />