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x4°4.Q �Q SAN JOAQUIN COUNTY <br />x COMMUNITY DEVELOPMENT DEPARTMENT <br />ism <br />:< <br />% <br />1810E wELTON AVE. STOWON. CA 95205 <br />C)MoPMENT SERVK=S (2091 468.3120 <br />d P1 QOM PHONE: 12091468-3120 <br />BU4DM PHoNEt (2091 468.3129 <br />NW44WRHOOD PRESERVATION PHONE (209' 468.3021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project <br />owner PA -N\( Phone No <br />Contractor _TDC- 00IPLu ► / - NO. License No. <br />INDICATE METHOD of BACRFZLL 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 />_Z <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 if or 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 fide.(5) cubicyards per 1000 gallon tank displacement and <br />kfilled:and compacted to insure compliance with the <br />that the entire excavation will bs'Ijac <br />Uniform Building Code Appendix Chapter 70. <br />K1 r151 <br />Name (Print) <br />* Shallbe the responsible managing, employee on the license or authorized <br />a e . <br />6/91-Lc/BECERT.DOC <br />