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0 <br /> SAN JOAQUIN COUNTY <br /> 1Qa Cp <br /> �.•.?" �;� COMMUNITY DEVELOPMENT DEPARTMENT <br /> Ie 10 E HAZ&TON AVE.,STOCu7ON.CA 95245 <br /> R8 <br /> }�r oe3&OPMEW SERVICES PHONE 12091 468.3120 <br /> FLANN1NG PHONE?12091 468-3120 <br /> 9ULMG PHONE:12041 468.3123 <br /> NEIGHSOAHOOO PRESERVATSON PHONE 12091 468.3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location <br /> Owner 1 [- Ql " �l�i P Phone No. <br /> Contractor Phone No . License No. <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Sail 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 /> Name (Print) <br /> tv �� <br /> T]. Le (Print <br /> Signature <br /> * employee on the license or authorized <br /> Shall be the responsible managing <br /> agent. <br /> 6/91-LC/BECERT.DCC <br />