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.*SAN SAN JOAQUIN COUNTY <br />r." �= COMMUNITY DEVELOPMENT DEPARTMENT <br />`� 1810 E HAZELTON AVE.- STOCKTON. CA 95205 90,91yZi •-.C,41PGP?�' DEVELOPMENT SERVICES PHONE 12091 466-3120PLANNING PHONE 12091 468-3120 <br />BUILDING PHONE (2091468-3123 <br />NEIGHBORHOOD PRESERVATION PHONE (2091 468-3021 <br />MAY 3 11994 <br />BACKFILL EXCAVATION CERTIFICATE IRONMENTAL HEALTH <br />PERMIT/SERVICES <br />Project Location <br />Owner -jys,% �c '' „�� _ �;. Phone No. <br />Contractor <br />Phone No. <br />License No. <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 />4- 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" I_Ut s : <br />f. <br />Pea gravel - smooth, rounded material not more than one-half (1/2) <br />inch in diameter. <br />S. 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 />Name (Print) <br />Tit <br />6 (Print <br />* Xl/' <br />"Signature <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />