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e u!h.. SAN JOAOUIN COUNTY,,,.*SAN <br /> DEVELOPMENT DEPARTMENT <br /> y <br /> • '.� 1610E HAZE7.TON AVE STOCMON.G 96205 - <br /> '••C I�B.d a`� DEVELOPMENT SERVICES PHONE 12091 468.3120 <br /> PLANNING PHONE 12091 466-3120 <br /> BUILDING PHONE 12091 466-3123 <br /> NEIGHBORHOOD PRESERVATION PHONE 12091 460-3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location _ q In1ESl l - 5T2FET' TR&Y CA gs376 <br /> Owner CrU 6F- TRA< Y. Phone No. XMA - 834 - yyZO <br /> Contractor WRr-6NT F1yUr L1AJM � Phone No.7�A-833-o7SX License No. 65-/S6/ <br /> ,6&ULC,F_S / rwc. <br /> / INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 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 /> inch in diameter. <br /> AB. 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 /> Name (Print) <br /> PP-t S.L.O ErUT <br /> T' le (Print) /p <br /> Sii nature / <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />