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.,OSAN SAN JOAQUIN COUNTY <br /> "' "=^ o <br /> �'; COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E HAZELTON AVE.STOCKTON,CA 95205 <br /> • +^I,gn?`� Oe&tOPMENT SERVICES PHONE 12091 466-3120 <br /> PUWNWO RHONE 12091 468.3120 <br /> BU8.08HG PHONE 12091 468-3123 <br /> NEIGHBORH000 PRESERVATION RHONE 11091 468-3021 <br /> BACKFILL EXCAVATION CERTIFFI/CCATE ✓1 / �� <br /> Pro ect Location <br /> Owner CikLfjJfIA1w Phone No. <br /> Contractor Z�� Phone No.'J y' License No. 14 �) <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> v 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'• Yts: <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 /> Nalene (P� � <br /> a . <br /> Tittle (Pr nt <br /> ignature <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />