Laserfiche WebLink
%gyp <br /> on <br /> SA,CKFILL EXCAVATION CERTIFICATE <br /> Prajecr i a=atiatt� <br /> 1-7100 Soo tvN A o r lan 12 Qo-k Leff rods , Cts <br /> Owner,_ Cas Dcn4er- Co . Phone two.a� r 982- ySDd <br /> Cottrracitsr VEI IV4Ot stn -rleerj n� --- Pttdue 1`[o-.�Q�- �(!v it��O f� l.icease Nu. $ �I i.0 �Z � <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Sail Engineer's Compactiou Report within 50 days of project completion,or <br /> Z. Submission of vmifcatim a.p load ticket, Widlin 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12' Una: <br /> A. Pea gravel--smooth, rounded meteriai not more than one-half(112)inch in diameter <br /> H. Crushed roe):--self-compacting imatcrial not more than --qquuartto (3/4) incl[ in cross seniotal <br /> measurement. (Use of crushed rode will not be permitted for backfill if ctmtact will be shade between the <br /> backfill mater€ad and tanks/pipes made of poly resin glans or similar materials.) <br /> DECLARATION , <br /> I hereby certify that a Soil Fagineer'e Compaction Report will be submitted within 30 days of TojM1 compkilan, or MAWnission of <br /> verifscatlon Lust the select material doscribed above will be placed at a miraimrun cd fire (� cubic yards,pg 100Q gallon tank <br /> displacement and that the attire excavation will be backfilled and compacted to insure compliance with tete Umfarm Bw'iding Code <br /> Appendix Chapter 70. <br /> W:ae C,orne 1� <br /> Name rut[ <br /> tt e <br /> ' .C -- <br /> tgnamre <br /> Shall be she tespmsible u►aoaging employee*0 the liccnae or authorized agm. <br />