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L' ���":�. SAN JOAQUIN COUNTY <br /> r.. s COMMUNITY DEVELOPMENT DEPARTMENT <br /> 4r 1810 E HAZELTON AVE, STOCKTON.CA 95205 <br /> C,t'ClCo*a�1• DEVELOPMENT SERVICES PHONE(209)468.3120 <br /> PLANNING PHONE (209)468.3120 <br /> BUILDING PHONE:(209) 468-3129 <br /> NEIGHBORHOOD PRESERVATION PHONE: 1209)468.3021 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> w. <br /> Project Location p5� (,L1 Ph1l� <br /> Owner 4, 7 /464-ne TQ Phone No. 16 t/r_,T- �35� <br /> Contractor r;Q�rgl� 1 Phone No. License No. <br /> hod <br /> .17 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> L 1. Submission of Soil 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 /> Ir 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 /> L.. inch in diameter. <br /> V B. Crushed rock - self-compacting material not more than three-quarters <br /> (3/4) inch in cross sectional measurement. (Use of crushed rock <br /> La 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 /> La 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 /> 160 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 /> J e,, 4 <br /> Name (Print) <br /> A <br /> i e Mae <br /> signs e <br />+. * Shall be the responsible managing employee on the license or authorized <br /> agent. <br /> 6/91-LC/BECERT.DOC <br /> Ir <br />