Laserfiche WebLink
OKFILL EXCAVATION CERTIFICATE <br /> rgentLtKadon; tJ -J Coo p. <br /> Phonc No: q 6 g2' I L ?' <br /> Owner] ' tdl L 0 <br /> Contractor: �4 �� � I � Phone No:3 Z5'-3 0'7-L tX7 License Tdo: E n <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineers Compaction Report within 30 days of project completion,or <br /> b� 2. Submission of verfrcation, e.g., load ticket,within 30 days of project completion that one of the following.materials was <br /> t <br /> placed in m excavation in I lifts: <br /> I A. Pea gravel--smooth,rounded material not more than one-half(1172)inch in diameter <br /> 13. Crushed rock--self-compacting material not more than three-quarters (314j inch is cross sccticraN <br /> --- measurement. (Use of crushed rock will not be permitted for backfill.if contact will be made bztvrcca the <br /> backfill material andtanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineers Compaction Report will be submitted within 30 da. s,of oject completion,or submission Of <br /> vesifleation that the select material described above will be placed at a minimum of tive (5 cubic yards per 1000 &alton tank <br /> displacement.snd that the entire excavation will be backfilled and compacted to insure compliance with the Unifom:Building Code <br /> Appendix atapter 70. <br /> /� ame rmt) <br /> x i e( not <br /> - t! _ <br /> signature <br /> s Shall be the responsible mzruiging employee on the license or authorized agent. <br /> EH 23 046 .(Revised I O/16!03) Page 11 <br />