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04-21-93 11:39AM P11 <br /> SAN JOAQUIN COUNTY <br /> sssr�� _ <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> l q III E NAMIGN AWL WWOOM.d 14701 <br /> DTVNMFMW GBR'=PNONE R0%440.3120 <br /> IpLAff"PNOW prim aw4120 <br /> SULOW PNONa R0"4403109 <br /> wsWeosgoo Pat10rn MN PMONE Rel 446301 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> (Ste Cmv,&r te'�V r i ewe g� <br /> Project Location <br /> Owner Phone No. <br /> Contract= <br /> Phone No. License No. <br /> INDICATR RMSOD or HAc9:YILL QUALITY ASSURANCE <br /> 1. Submission of Soil Enginesr•s Compaction Report within 30 days Of project <br /> completion, or <br /> within <br /> s Of <br /> Oct <br /> '. Submission of <br /> that one verification, <br /> the followinglticket, <br /> was placed in they excavations <br /> cin <br /> 12" lifts: <br /> A. pea gravel - smooth, rounded material not more than one-half (1/2) <br /> — inch in diameter. <br /> material not <br /> re <br /> B. (3/a)dinch in creme osectionnal measurement. o (Uses three-quarters <br /> rock - of crushed rock <br /> will not be permitted for backfill if contact will be mads lute en <br /> the backfill material and tanks/pipes mads of poly g <br /> or <br /> similar materials.) <br /> DECLhRATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> scribed above <br /> wof prill b pl coedlatianminimum ofSfiveols)8cubicayards perthat tl000 gallhe selectatank al do <br /> displacement and <br /> that the entire excavation will be backfilled and compacted to ineure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> e <br /> Name (Pr nt <br /> Title (Pr n <br /> S gnature <br /> * Shall be the responsible managing employee on the license or authorised <br /> agent. <br /> 6/41-LC/HHCERT.DOC <br />