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Vitt. SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />1810 E. HAZELTON AVE.. STOCKTON, CA 95205 <br />aA�►`' DEVELOPMENT SERVICES PHONE (209) 468-3120 <br />PLANNING PHONE 1209) 468.3120 <br />BUILDING PHONE (209) 468.3123 <br />NEIGHBORHOOD PRESERVATION PHONE (209) 468.3021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location [�;Nr,_z10t <br />Owner Phone No. <br />qu <br />Contractor ` �s ,,�,av,, ei hone No. ?ra]4j4 Z License No. �oR3 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. <br />Submission <br />of Soil Engineer's Compaction Report within 30 days of project <br />completion, <br />or <br />t/ 2. <br />Submission <br />of verification, e.g. load ticket, within 30 days of project <br />in the excavation in <br />completion <br />that one of the following materials was placed <br />12" lifts: <br />Pea gravel - smooth, rounded material not more than one-half (1/2) <br />inch in diameter. <br />B. <br />Crushed rock - self -compacting material not more than three-quarters <br />rock <br />(3/4) inch in cross sectional measurement. (Use of crushed <br />be for backfill if contact will be made between <br />will not permitted <br />the backfill material and tanks/pipes made of poly resin glass or <br />similar materials.) <br />DECLARATION <br />I hereby <br />certify that <br />a Soil Engineer's Compaction Report will be submitted within 30 days <br />the select material described above <br />of project completion, or submission of verification that <br />per 1000 gallon tank displacement and <br />will be <br />placed at a minimum of five (5) cubic yards <br />will be backfilled and compacted to insure compliance with the <br />that the <br />Uniform <br />entire excavation <br />Building Code <br />Appendix Chapter 70. <br />Name (Print) <br />Zignature <br />le (Prin <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />