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S O N J O A Q U I N Environmental Health Department <br /> faCOUNTl�Y-19 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Locatioi, Ja� �vim. Co <br /> Owner r✓ Phone No :6A "03 <br /> Contractor: �� clg n 4q>vl�17 /0o Phone No : <br /> License 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 completion <br /> that one of the following materials was placed in the excavation in 12 ' lifts : <br /> _A. Pea gravel--smooth , rounded material not more than one-half (1 /2) <br /> inch in diameter <br /> V/B . Crushed rock--self-compacting material not more than three- <br /> - quarters (3/4) inch in cross sectional measurement. (Use of <br /> 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 <br /> glass or similar materials .) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 <br /> days of project completion , or submission of verification that the select material <br /> described above will be placed at a minimum of five (5) cubic yards per 1000 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure <br /> compliance with the Uniform Building Code Appendix Chapter 70.nnt <br /> Title <br /> �71r <br /> rent <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> 10 0f 10 <br />