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SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />1610 E R4MTON AVE. STOCKTON, CA 95205 <br />OEVELOPIAENT SERVICES PHONE 12091 466.3120 <br />PLANNING PHONE 12091 AGS -3120 <br />BUILDING PHONE (2091 468-3123 <br />NEIGHBOM4000 PSESEAVATION PHONE (2091 466.3021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location '3011 _F3&!W,\i:tiln,W ►n;T bklAy- 5_MC1C o10 <br />Owner 01(-- coiv\PA�JPhone No. <br />�( <br />ContractorPhone NoO/G T�c License No. <br />C�/tiS� u'uCflcL�� 94� -24 <br />INDICATE METHOD OF BAC%FILL 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" lifts: <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 />C <br />CiL <br />Name (Print) <br />(J 1 -ILC, -GJ- <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />