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SAN JOAOUIN.COUNt <br /> COMMUNITY DEVELOP <br /> -NT UPl�AFiTMpNT <br /> 1910 E t"LTO►1 AVE. s1oC"M)-CA 95705 <br /> r�ljrlS�il`r otvaoPwt" sErwlGEs P010m.. 12091460-3120 <br /> r'im)PwtO P iouF:poo X69 mvt <br /> 11V�L[uN0 rfK1r1E:P091 469.117) <br /> numiSor"t000 rnesERVAnoN mitt --12091 469.3021 <br /> i <br /> u <br /> BACKFILL EXCAVATION CERTIFICATE <br /> o ject bocatlon 900 112 E. Victor Rd. Lodi, CA 95240 <br /> tier Teresi Trucking Phone No. (2091368--2472 <br /> a i <br /> f fltrac:L-or Jim Thorpe Oil, Inc. Phone No (209)368-6175 License No. 495699 <br /> .1 <br /> 111DICATE METHOD of BACKFILL QUALITY ASSUPivieE <br /> �1 <br /> I . Submission of SOLI ErtgLneer'a Compact Lon Reportwithin 30 days of project <br /> completion, or If <br /> .7. Submission of verification, e.g. load ticket, "wlthln 30 days of project <br /> camp l.et1.on that one of the following materials wag pla6ed In the excavation In <br /> lifter <br /> _-y A. Pea gravel - smooth, rounded material ?}not more than one-hair (1/2) <br /> inch in diameter. <br /> i� <br /> B. Crushed rock - self--compacting material not more than three-quarters <br /> (3/4) inch in cross sectional measurement: (lfse of crushed rack <br /> will not be permitted for backfill lf !,contact will be made between i <br /> the backfill material and tanks/plpes)made� of poly resin glass or <br /> slmilar materials. ) <br /> DECLARAT10N <br /> lertiby certify that a Soil Engineer's Compaction Report willibe submitted within 30 days <br /> Project-_ completion, or submigplon of verification that the select material described above <br /> I be placed at a minimum of five (5) cubic yards per 1000 'gallon tank displacement and <br /> t the entire excavation will bp backfilled and compacted to lneirre compliance with the <br /> form Building Code Appendix Chapter 70. i <br /> * Jim Thorpe Oil, Inc. dba Rich-Mart Construction <br /> Name (Pr nt)� <br /> Contractor <br /> TIti (P 'nt <br /> President <br /> "813I.gnature <br /> ,'f <br /> Shall be the responsible managing employee on ttie license or authorized . <br /> agent. G <br /> 1-1,C/EIECERI'.bOC <br /> .c <br />