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.*SAN SAN JOAQUIN COUNTY <br />?,,, �' o <br />r.' ;.i COMMUNITY DEVELOPMENTAR <br />1610 E HAMTON AVE, STOORON, CA 95205 <br />...0 I'Ody.� DEVELOPMENT SERVICES PHONE (209) 468-3120 <br />PLANNING PHONE 12091 468.3120 <br />BUILOING PHONE 12091 468.3123 <br />NBGHBOR4000 PRESERVATION PHONE 12091 468-3021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project <br />++Location 23yQ/ S C6/Yt/S/If I ka %l+GN <br />�(- <br />Owner Lk9(. UArJ 'k0PATi>? Phone No.C�pg1 a �SZ//!5-- <br />ContractorALL �NU�l20liti(Briitg I�IkPhone No.�jj le2p32,3_�License No. 6'�yy19 <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 <br />completion that one of the following materials was placed in the excavation in <br />12" lifts: <br />XA. 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 />* <br />* .��m)n�1r-�rL �oU_MCT-' <br />Name (Print) <br />shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/SECERT.DOC <br />