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....*SAN SAN JOAQUIN COUNTY <br /> �y >�°c <br /> •, ;:� COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E WELTON AVE,S700,70N,CA 95205 <br /> • c�" y'H DEVELOPMENT SERVICES PHONE 12091 4683120 <br /> rve'« <br /> PLANMNO PHONE 12091 4683120 <br /> BURRING PHONE 1209)4683123 <br /> NEIGHBORHOOD PRESERVATION PHONE(209) 4683021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location <br /> Owner Phone No. <br /> Contractor Phone No. License No. <br /> INDICATE HETBOD 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 /> ,t <br /> Name (Print) <br /> Title (Print) <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECEAT.DOC <br />