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SAN JOAQUIN_COUN <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> • 1910 E rV1 WON AVE., STOCK W CA 9520s <br /> riZlHtyAi►`r oEvEEormurT SEswES rmotiF- I2o9} e69•3t2o <br /> rthNrn�ip rt10F1E:X2091 �6eiize <br /> (tlF1.OING rTi0t7E:�209� X68 3123 <br /> NM"301"1000 PMSERVATTON PHONE 1209 468-302t <br /> BACKFILL EXCAVATION CERTIFICATE <br /> roject Location 900 112 E. Victor Rd. Lodi, CA 95240 <br /> wrier Teresi TruckingPhone No. i(209)368-2472 <br /> orTtractor dim Thorpe Oil, Inc. phone No• {209)368-6175 La cense No. 495699 <br /> i` <br /> irrnxCATE HETROD or BACKFILL QUA.WTx ASSURAN69 <br /> 1 . Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> X 2. Submission of verification, e.g. load ticket, ,GwithFin 30 days of project <br /> completion that one of the following materials was placed In the excavation In <br /> 12." liftst <br /> _ A. Pea gravel -- smooth, rounded material` not more than one-half (1/2) <br /> Inch in diameter. <br /> IL <br /> e. 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 l0 contact will be made between <br /> the backfill material and tanks/pipes made of poly resin glass or <br /> similar materials. ) <br /> .r <br /> DECLARATION <br /> hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> project, completion, or submisgion of verification that the select material described above <br /> 11 be placed at a minimum of five (5) cubic yards per 10001�gall8n tank displacement and <br /> at the entire excavation ca anon will be backfilled and compacted t'o lneure compliance with the <br /> Iform Building Code Appendix chapter 70. <br /> * Jim Thorpe Oil, Inc. dba Rich-Mart Construction <br /> Name (Print) <br /> Contractor ;f <br /> Ti (P t <br /> President <br /> lgnature <br /> Shall be the responsible managing employee an the license or authorized <br /> agent. 'g <br /> 91—LC/$ECERT.DOC <br /> I <br />