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SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />te10 E HAZELTON AVE. STOCKTON. CA 95205 <br />DEVELOPMENT SERVICES PHONE 1209) 468.3120 <br />PLANNING PHONE 12091468-3120 <br />BUILDING PHONE 12091 468.3123 <br />NEIGHBORHOOD PRESERVATION PHONE (209) 4683021 <br />Project Location <br />Owner <br />Contractor <br />BACKFILL EXCAVATION CERTIFICATE <br />Phone No. <br />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 <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 />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 />Name (Print) _ <br />Title (Print) <br />,t <br />Signature <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />