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SAN .J0AQUIN <br /> Environmental Health Department <br /> — COUNTY— <br /> FEB 0 7 2018 <br /> BACKFILL EXCAVATION CERTIFICATE ENVIPiONMENT �L i;1"PUTH <br /> 1 I`i�..i•tl� �'� )4�/{Is IiIT <br /> Project Location : �, itY� + No�i : r OCC4 <br /> Ownerk@ t'f�c �l Phone No: � <br /> Contractor: ``+ v Cy l\YaL` 4 ° �>>rJJ '� • Phone No: (12S) <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 pro'ect completion <br /> that one of the following materials was placed in the excavation in 12 ' lifts: <br /> A. Pea Qravekmsmooth, rounded material not more than one-half ( 1 /2) <br /> inch in diameter <br /> 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 . <br /> *Name <br /> (Print) <br /> Title <br /> not <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> 10otto <br />