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San Joaquin County 000zzo <br /> Cornmunity Devcl=ent Depa= <br /> 1810 E. Hazelton Avenue,Stockton,CA 95205 <br /> Development Services Phone: (209)468-3120 <br /> Planning Phone: (209) 468-3120 <br /> Building Phone: (209)468-3123 <br /> Neighborhood Preservation Phone: (209)468-3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location L_LN L S l T 2,3 QQ (E)V 1 tai N(a .$a`7 <br /> Owner LLN L Phone No. —S)O - t-f ot3 -H` b 1 <br /> Contractor?`u►rW T`C..1� _ Phone No.yo$-LIS3-I'M License No. 59 O a9 S <br /> INDICATE METHOD OF BACKFILL QUALI'T'Y ASSURANCE <br /> X 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> 2. Submission of verification,e.g.,load ticket,within 30 days of project completion that one of the following <br /> materials was placed in the excavation in 12"lifts: <br /> A. Pea gravel-smooth,rounded material not more than one-half(1/2)inch in diameter. <br /> B. Crushed rock-self-compacting material not more than three-quarters(3/4)inch in cross sectional <br /> measurement. (Use of crushed rock will not be permitted for backfill if contact will be made <br /> between the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion,or <br /> submission of verification that the select material described above will be placed at a minimum of five(5)cubic yards per <br /> 1000 gallon tank displacement and 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 /> CJ NSiirwGL 10 3 )t►A 0 A Vu._ <br /> Title(Print) <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> 6/91-LC/BECERT.DOC <br /> 12 <br />