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s <br /> e <br /> San Joaquin C runty e <br /> Community D. -ehnient Department <br /> 1810 E. Hazelum Avenue.Sux;klom.CA 952415, <br /> Development Sen ;ea Phone: (2(Y))4li?t• 1211 <br /> Plannine Phone: i.1r)) 4&X-112() <br /> Building Ptione: (209)469-312? <br /> Neightxhrfhexxl Prese�rvatiewh i'ixwh6: (24191.t(u(-74121 <br /> BACKFILL EXCAVATION rERTU•-ICATE <br /> Project Location I ® Nl.. S iT L 300 Z LDi N6 6 c' <br /> owner i d' L-N Plumc No. S 17 921 ey11t'1 <br /> Contractor 9`c_1 fV1 Phone Nol'd License No. l J� 5 <br /> INDICATE METHOD OF BArKFILL QUALITY ASSURANCE <br /> i. Submission of Soil Ensincer a Compaction Regxirt within 30 days of project completion.or <br /> 2. Submission of verification.Cs..load ticket.within 30 days of project completion that one of die following <br /> materials ca&%placed in Ute excavation in 12"lifts: <br /> A. Pea gravel-smooth.rounded material neo more than one-half(1R)inch in diameter. <br /> B. Crushed neck-klf-�txttl+:xting ituteriai neo tntwe Ut:m thri-e-quarters l3/4)itx h in e7uss sectional <br /> meawrement. (t ke of rushed nock will nut he permitted for backtill if contact will be Mack <br /> httwe'en tit backfill material and tan6tipes made of poly renin glass or similar materials.) <br /> DELI-ARATION <br /> I hereby certify that a Soil Enginec°r%Compaction Reptwt will h<submitted within 30 days of project completion.or <br /> submission of verific:uion that the select materul dexrihed alxeve will be ptace-d at a minimum of five(5)cubic yards per <br /> 1000 gallon tank displacement:mei that the entire excavatiexh will be hackfilled and compacted to insure compliance with the <br /> Uniform Building Ccxk:Appetdix Chapter 70. <br /> -N A22:.�zA—, <br /> Natne(Print) <br /> �.c�uS't'(U)�'D IoIJ ANAGf�.. <br /> Tak nt) <br /> Signature <br /> • Shall be the responsible managing employee on the license or audhorized agent. <br /> 6191-LCJB%CERT.DOC <br /> J <br /> 12 <br />