539 ATLANTIC BEACH CT - FORM BOARD ELEV 4
S PIeese
FORM BOARD `ELEVATION CERTIFICATE
Duval County / Clay County
✓ Left copy on site No box
Lot and Subdivision: Go r z` �T�,nlrc ���� «
DATE: of/o y/ie •
PERMIT
NUMBER: ; 7 . 0Z2- 3
ADDRESS: 5 3 9 g T, G /T
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: , o• yo
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: ii. s.—
SURVEY COMPANY
NAME: Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
Corporate .
. Ey1 Ellis&Associates Inc. 7064 Davis Creek Road,Jacksonville,FL 32256 P:(904)880-0960 F:(904)880-0970
EGroup of Companies Branch Location:
Geotechnical•Construction Materials•Environmental•Facilities Brunswick: 134 Newman Drive,Brunswick,GA 31520 P:(912)279-0085 F:(912)279-0086
Daytona: 2706 S.Ridgewood Ave.,Suite 2 P:(386)944-9588 F:(386)944-9589
ellisassoc.com South Daytona,FL 32119
Work Order#:
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#: _ t
Subdivision: i>"L. It Reported to: Report#:
Unit or Parcel: Location By: Gauge#:
``
Lot#Block: Contractor:
Date Tested:
Street Address: S. 9 . %t k.'!..,-7, ?.„, - ( City: r •,
Method: Course: w t_ L_
Material: Specific Requirements: -'-,‘"1—)
Pass/ Elev/ Base/LR/ Dry Max. Dry % of Max Moist
Fail/ Location Depth Asphalt/ Density Density* Density %
Retest /Lift Thickness
)/r C- ,/.....,•z 7-2 ,z
C r4T c^t- _ /.__�- L ��-V 1
*Source of Proctor (Project# and/or Work Order#)
r P- Test Meets Specification Requirements F- Test Fails To Meet Specification Requirements R- Retest
To Be Completed In Field
1
Employee Name Standby Approval
(
Time Superintendent Printed Name
Start/Stop Travel Standby Job
Superintendent Signature
(Office use)
EA-10(rev.04/16) white copy-office use yellow copy-personal use pink and goldenrod-client use Page of r