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AN '9a IQ= 2 R.H.L.�PETUffA <br /> 0 <br /> ,.�• SAN JOAOU*% ,C:NTY <br /> 1 COMMUNITY ;EVE OPMENT DEPARTMENT <br /> rii9 C fliG<'•1 =:��,QN,CA WQS <br /> -3170 <br /> IC;ZFILL EXCAVATION CIATIVICATU <br /> Project LocationiiG LU '1;? <br /> Owner FACIMO. phone Na. tri•11Z ` <br /> contractor gW,014 hone No. License No. <br /> HEIROD OF BACKFILL QUALI7r RssvF.I CE <br /> 1. Submission .s St'1 Engi.naer`s compact=or, Aoport within 30 days Z'. a- jcct , <br /> completion, r: <br /> Z. Su3-►istr_aa :` ve_ifieation, e.g. load ticket, with; 30 usgs c: ,,a�ecti <br /> completion ,'at -.8 of the following r.&terial■ was placed in the z�cc„'===OR in <br /> 12' lits: <br /> s-..qaoth, rouet9d material nct more than cne'!%alf 0121 <br /> —' ;sc'I�'n diameter- <br /> 8. c;-shad reck - self-compacting material not more than thrrz_gLazt4rsf <br /> (!!4) inch in craze sectional r,saasuranQZt. (Lyse of c_vshed rock <br /> __,l riot be permit,ed for backfill if ccntact will bra mode =etwgsr9 <br /> tie Lacitfill metarial &Pd tanks/pipes rade of poky rc■:n glass or <br /> ■°-.11sr rs8teria2e.j <br /> DE�CLAAATION <br /> I hereby certify that a fail Engineer's Compaction Report will be 6ubm'ttrd v1t"n 30 days <br /> of prv1ect co-ylQtion, or submission of verification that the select material descried above <br /> will be placed at a minimum of five (5) cubic yards per 1000 gallon tisk d i&ncetwithPent and <br /> that the ■ntize excavatica will be backfilled and compacted to insure ccaapliaace With tY�ss <br /> Unifvz'm building Code AF;*adix chapter 70. <br /> r nt <br /> T P <br /> S1g ature <br /> # Shall be the responsible managing employee on 'the licanae or authorized <br /> agent_ <br /> st/'32-Lc jsscEitT.Doc <br />