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f <br />►,V.aIn. SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E. HAZELTON AVE., SrOCKION, CA 95205 <br />DEVELOPMENT SERVICES PHONE: (2091 4603120 <br />PLANNING PHONE: (209) 460.3120 <br />BUILDING Pi ZONE: 12091 4603123 <br />NEIGHBOMOOD PRESFIIVAIION PHONE: (2091 460.3021 <br />DACKFILL EXCAVATION CERTIFICATE <br />Project Location <br />'S a --'T 0 <br />n <br />Owner FICA P�� K� Phone No. <br />Contracto ►i SC r .! Phone No��-+! ''� License No. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission <br />of Soil Engineer's Compaction Report <br />within <br />30 clays of project <br />completion, <br />or <br />2. Submission <br />of verification, e.g. load ticket, <br />within <br />30 days of project <br />V <br />_ completion <br />that one of the following materials was <br />placed <br />in the excavation in <br />12" lifts: <br />V �'• <br />Pea gravel - smooth, rounded material <br />not more than one-half (1/2) <br />Inch in diameter. <br />Crushed rock - self -compacting material not more than three-quarters <br />B. <br />(3/4) inch in cross sectional measurement. <br />(Use of crushed rock <br />will not be permitted for backfill if <br />contact <br />will be made between <br />the backfill material and tanks/pipes <br />made of <br />poly resin glass or <br />similar materials.) <br />DECLARA'1ION <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 />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />