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.(`cl. <br /> .��,d. SAN JOAQUIN COUNTY <br /> .(*SAN <br /> DEVELOPMENT DEPARTMENT <br /> k .� 1810 E WELTON AVE.,STOCKTON,CA 95205 <br /> 'IYN*'� DEVELOPMENT SEnVICES PHONE )209)4683120 <br /> PLANNNO PHONE:)209)466-3120 <br /> SU40MG PHONE)209)4683123 <br /> NVGH9OnHOOD PnESENVATION PHONE )209) 4683021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> P ojectLocation _3//p 'J 'VV/6 &qd <br /> 9_kt66r <br /> 4-c 6)ISo. <br /> Owner , Tic, f7' F�Gl.�wci/���,.r t 3`T Phone No. CJ4� 7,�-�'(p -��� - <br /> Contrap��� !S4- r� l <br /> otb C�`(Li)UI/b,)m�(��g��.zPhone NoZ�)/G7S `l3Si� License No. (WSIY,_ A4 79Z <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•' lifter <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 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 /> . alelldra,7 <br /> Name (Print) <br /> �es) fed, <br /> Title (Print) <br /> Signatur <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />