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°w SAN JOAQUIN COUNTY <br /> �y <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1610 E HAZEUON AVE STOCIOON.CA 95205 <br /> •.•O ;i+u A+�' 0MOPMPNT SERVICES R4ONe 1209)458-3120 <br /> PIANNMG PHOHE rt091 466-3120 <br /> SULa W3 RIONe MM 46&3123 <br /> NOGMORHOOD PRESEFNAIM PHONE:(2091468-3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Erroject Location S �ltw <br /> rner CenAj I A GOA- �� CfKA Phone No. 9 1/�e� '3��g <br /> t� }" <br /> Contractor �+�k ywurryyy� Phone No. .71 �Jti�i License No. S <br /> QfaS <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 /> V1 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 /> Crck - self-compacting material not more than three-quarters <br /> ushed ro <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 /> ^f project completion, or submission of verification that the select material described above <br /> ill be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> ,hat the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> Name (Print) <br /> Titley <br /> — ignature <br /> k Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />