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(-0 co <br /> SAN JOAQUIN COUNTY <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> m• <br /> ! �= 1010 E WELTON AVE.STOCKTON,CA 95205 <br /> • �`� lt5a�'` DEVELOPMENT SERVICES PHONE 12051 468-3120 <br /> PLANN NG PHONE 1209)468-3120 <br /> SUILDING PHONE 12091468-3123 <br /> NETGI48OR1400D PRESERVATION PHONE(2091468-3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location � �J J011 ')>,J D, t_TA <br /> ' Owner TOS I ACr i Q A1. _ <br /> Phone Nv. - �� <br /> co Phone No. 4RSF-34S� License No. ? 3 5r5�o <br /> Contractor A A)�S -� <br /> 1 INDICATE METHOD OF BACKFILL QUALITY ASSURJLNCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> oad <br /> within <br /> s of <br /> ctn <br /> 2. Submission of verification,completion that one of the following lmate materials wras placed in hey excavationein <br /> ' 12" lifts: <br /> f A. Pea gravel - smooth, rounded material not more than one <br /> tl/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 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 /> 1 JOW 010o/z, <br /> Name (Print) <br /> Title (Print) <br /> ignature <br /> Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> ! 6/41-LC/SECERT-DOC <br /> ! <br />