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DTFSAN JOA UI COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />w �;1810 E IWFLTON AVE. S7OCKTOR rA 95205 <br />DEVELOPMENT SERNCES PHONE 12091 468-3120 <br />PLANWIG PHONE 12091 468-3120 <br />BUILDING PHONE 12091 4683123 <br />NEIGHBORHOOD PRESEI1vAnON PHONE 12091 4683021 <br />HACRFILL EXCAVATION CERTIFICATE <br />Project Location 7500 W Linne Road Tracy CA 95376 <br />Owner Jefferson School District Phone NO. (209)836-3388 <br />Contractor Jim Thorpe Oil, Inc. Phone No. (209)368-6175 License No. 495699 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. <br />Submission of Soil Engineer's Compaction Report <br />within 30 days of project <br />_ <br />completion, or <br />7. <br />Submission of verification, e.g. load ticket, <br />within 30 days of project <br />-- <br />completion that one of the following materials was <br />placed in the excavation In <br />12" lifts: <br />X A. Pea gravel - smooth, rounded material <br />not more than one-half (1/2,) <br />Inch in diameter. <br />B. Crushed rock - self -compacting material <br />not more than three-quarters <br />_ <br />(3/4) inch in cross sectional measurement. (Use of crushed rock <br />will not be permitted for backfill if <br />contact will be made between <br />the backfill material and tanks/pipes <br />made of poly resin glass or <br />similar materials.) <br />DECLARATION <br />I hereby <br />certify that a Soil Engineer's Compaction Report will <br />be submitted within 30 days <br />of project completion, or submission of verification that the select <br />material described above <br />will be <br />placed at a minimum of five (5) cubic yards per 1000 <br />gallon tank displacement and <br />that the <br />entire excavation will be backfllled and compacted to insure compliance with the <br />Uniform <br />Building Code Appendix chapter 70. <br />* Richard Thorpe/ Contractor <br />Name (Print) <br />President/ Jim Thorpe Oil Inc. _ <br />Tit (Print <br />lgnature <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />