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SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />16to E HAZELTON aVE_ 400CTCN. G 95205 <br />•:C��iY DEVELOPMENT SEAVIC3 PHONE 12091 4664120 <br />P,PNNING PHONE 12091 4664120 <br />9UILCING PHONE (2091 466.3127 <br />NEIGH6CHN000 PPESEAVATICH PHONE (2091 466-7021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location S 4 AA f% 1Z Sr. / <br />Owner /�"I�KL/ Cs- osAN �RTa�/ Phone No. (7,0q� %3) <br />Contractor TIj1 Phone _LL:2tfn License No. �7(o f60 <br />339 -871 S <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" 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 he 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 />x <br />Name (Print) <br />Title (Print) <br />Signature <br />Shall be the responsible managing emplovee on the license or authorized <br />agent. <br />6/91-LC/BECERT-OCC <br />