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.a+n. SAN JOAQUIN COUNTY <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> �- 1810 E HAMTON AVE STOCKTON,CA 95205 <br /> ••"•l�d•�ye�`� DEVELOPMENT SUMCES PHONE 12091468-3120 <br /> PLO"NG PHONE 12091 188.3120 - <br /> B=ING PHONE 12091468.3f23 <br /> NeGHSORH000 PRESERVATION PHONE(209)4664021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location I0067 �(i Amo-d 5- JiOell4a-0 &4- <br /> Owner t9014 -8016✓ Phone No. (Q,D4, -1t13•-72j37 / <br /> Contractor S'E/n e,0 Phone No.Zaf _ZS1 r/ 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 prcject <br /> completion that one of the following materials was placed in the excavation in <br /> 12" lifts: <br /> V__�A. Pea gravel - smooth, rounded material not more than one-half (1/2) <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 for 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 five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> aW(Pe&, <br /> rint)A///�1A <br /> // � <br /> , .I/ <br /> ,Title (Print) <br /> * C—, <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized <br /> I <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />