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1 <br /> SAN JOAQUIN COUNTY <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> I I,+.Y.u:.lUllti <br /> 11fluilwlN `'..I ' <br /> • Ia10 E.102ELION AVE-,9TOMON.CA 95205 <br /> i'f4jik DEVELOPMENT&EFiVICES P1iQNE 3T091�68.31�0 ' <br /> PtAntANO PIIONE!12091468-3120 1; <br /> aMOING <br /> NEIGI BORIIWO PIFIESERVATI3 <br /> ONPHONE'1201460-;021 � <br /> BACKFILL EXUAVATIoN CERTIVIOATE <br /> Project Location z 3 S� _ <br /> t)wlter <br /> ) 7-1,_ro Phone No. - <br /> _ zo ,- <br /> contractors c o.L.,u(�.Pilaiia No. License NO.,56,f( <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1 . Submission of Soil Engineer's Compaction Report within 30 days of [)10i. 1 <br /> -" completion, or <br /> i <br /> 2. Submission of verification, e.g. load ticket, within 30 clays of poll-I <br /> completion that one of the following materials was placed in the excay.►tiull <br /> 12" 1'iftel <br /> t/ Pea gravel -- smooth, rounded material not more tlTan 0t)[33--hil l f { I <br /> inch in diameter. <br /> B. crushed rook - self-compacting material not more than three'-+:Iu.11 <br /> (3/4) inch in arose sectional measurement. (Use of crunfietl t. <br /> will not be permitted for backfill if contact will be made llt,tu+, '1I <br /> the backfill material and tanks/pipes made of poly r©al.I1 <br /> similar materials. ) <br /> DECLARATION <br /> I hereby certify 'that a soil Engineer's Compaction Report will be submitted withiil :30 <br /> L,f project completion, or submission of verification that the select material deecri.ljed at: <br /> l�i.il be placed at a minifium of five �S) cubic yards per 1000 gallon tank displacem1 <br /> etJ . L <br /> i Ilat the entire excavation will be backfilled and compacted to inure compliance 4,.it 11 i .� <br /> Ilili.lorm Building code Appendix Chapter 70. <br /> j Name (Print) <br /> Sgnaue <br /> employse on the license or <br /> A shall be the responsible managing <br /> agent. <br /> r <br /> 6/91-LC/BECERT.DOC <br />