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Q,,au'n• SAN JOAQUIN COUNTY <br /> x•�Q••o <br /> COMMUNITY DEVELOPMENT DEPARTMENT <br /> 1810 E HAZEI-TON AVE,STOCKTON•CA 95205 <br /> Gii1a'a�'�* IS <br /> SERVICES PHONE 1209)468.3120 <br /> PLANNING PHONE(2091 468-3120 <br /> BUILDING PHONE(2091468-3 123 <br /> NSGHBORH000 PRESERVATION PHONE(2091 468.3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 401 X12 j <br /> OwnerInlThone No. (ZCD`?,) 5e-3 �3¢2- <br /> Contractor ` NrS l D� UCS j6jJ Phone No.C' )M-(AALicense, No. <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> _Z2. 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 /> �• 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 /> V)N CIE=- <br /> Name (Print) �p�� <br /> i e Pri <br /> l <br /> Signa r <br /> * Shall be the responsible managing employ on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br />