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a SAN JOAQUIN COUNTY <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1610 E HAMILTON AVE,STOCKTON.CA 95205 <br /> • +'gyp -�?`� DEVELOPMENT SFJMCES PHONE 12091 468-3120 <br /> PIANMNG PHONE 12091 468-3120 <br /> BURDMG PHONE 12091 468.3123 <br /> NEIGHBORHOOD PRESERVATION PHONE 12091 468-3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location /D IUcSi [TRAIvr LINL kbA01, 7,2AG/ C4 yS376 <br /> Owner GL 7-1y6f 7764cY Phone No. <br /> Contractor kXr6NT r:.A.1ghone No. -Zpy-$,;;-p7SS! License No. A,,5/,SO/ <br /> fFAdtccS/ LNG <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 /> * )o ILIA) G YNCN <br /> Name (Print) <br /> Ti e (Print) <br /> �nature <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />