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r� <br />• r� <br />,�¢uIn• SAN JOAQUIN COUNTY <br />r COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E HAZELTON AvF_ STOWON, CA 95205 <br />OEVELOPMENT SEWCES PHONE 1209) 468.3120 <br />PLANNING PHONE (2091 468.3110 <br />BUILDING PHONE (209( 468.3123 <br />NEIGHBOAH000 PAESEWATION PHONE (209) 468.3021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location���� <br />Owner1i1 �f� (,j Phone No. ( ) Lc(r) y LC I ` c�) <br />Contractor Phone No (f -,1G L4icense No. <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" lifts: <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 />I rr L. E -to,_ . c <br />Name (Print) <br />?ro j c cel, C ocq t' aJa _ <br />itle (Priinnt) <br />Signature <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />