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�..A SAN JOAQUIN COUNTY <br /> r.'�' +� COMMUNITY DEVELOPMENT DEPARTMENT <br /> .*SAN <br /> 1 <br /> u � I810 E HAZELTON AVE.,STOCKTON,CA 95205 <br /> �I Tkd*ii:. DEVELOPMENT SERVICES PHONE 12091 4683120 <br /> PLANNING PHONE 12091 4664120 <br /> BUILDING PHONE:(2091468-3123 <br /> NEIGHBORHOOD PRESERVATION PHONE 12091 4663021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> P of ect Location ,�/�/ 7 7 GAP �r�m�!!lPl / 7 <br /> Owner .�SPIZ-{o, A5v/uav �'r �a�T Phone No. <br /> Contr�actbF/1L1((otme6Ct���� ✓CPhone Norl7S g3Se License No. A-1f4Z <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 /> completion that one of the following materials was placed in the excavation in <br /> 12" lifter <br /> 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 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 /> * j a 6 ielj(4� <br /> Name (Print) <br /> fires I de.; <br /> Title (Print) <br /> gnature <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />