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*SAN JOAQUIN COUNTY <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E WELTON AVE.STOCKTON.CA 95205 <br /> DEVELOPMENT SERVICES PHONE (209) 468-3120 <br /> PLANNING PHONE(209)468-3120 <br /> BUILDING PHONE(209)468-3123 <br /> NEIGHBORHOOD PRESEWATION PHONE(2091 468.3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 7 2 <br /> Owner C_( � �6* S �c11i✓11�CauiA�v Phone No. H�e� 'J �J9 <br /> ContractoryC � Phone No. 7�{S�� License No. <br /> enN_INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer' s Compaction Report within 30 days of project <br /> / completion, or <br /> V 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 /> _L/ 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 /> Name (Print) <br /> 0 ISVti� 7`n l /c-6 <br /> Title r <br /> >t� <br /> ignature <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />