526 Atlantic Beach Ct Form Board FORM BOARD ELEVATION CERTIFICATE
Duval County I Clay County/ Nassau County
Left copy on site Elko box
Lot and Subdivision: 1,61r-Z3 i4TL4.u7xC gE4
DATE: A) -27 - /B
PERMIT
NUMBER: OZ97
ADDRESS: 5ZG ATGRn,T2c gEAly ' �
R&S is-- o2e7
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: 930
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: /D- G2-
SURVEY
2SURVEY COMPANY
NAME: Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
> Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
C.rn�,v✓- ��w .
. Jacksonville II
C 70M Davis Creek Road,Jacksonville,FL 32256 P:(904)880-0960 F:(904)680-0970
Brunswick
134 Newman Dnva,Brunswick,GA 31520 P:(912)279-0085 R(912)279-0)85
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cslimi ed.co
ecslimited.com
Work Order#:
REPORT OF IN PLACE DENSITY RESIDENTIAL Project H:
Subdivision: — c t Reported to: Report 8:
Gauge#:
Unit or Parcel: Location By: i i
Daze Tested: //
Lot#Block: z Contractor.t •�<' � �
Street Address:
74, i' iu,,.-.c ax..,[t' City:
Method: Course:
Material: Specific Requirements: •>�
Pass/ Elev/ Base/LR/ o
Dry Maz.Dry /°of Ma: Moist
Fait/ Location (Depth Asphalt/ Density Density' Density
Retest /Lift Thickness
I
•Source of Proctor(Project#and/or Work Order#)
P-Test Meets Specification Requirements F-Test Fails To Meet Specification Requirements R-Retest
To Be Completed Infield -------------------"
`�. .--------Standby Approval
Employee Name t
Time - Superintendent Printed Name
/S
Superintendent
Travel Standb - Job
Superintendent Signature
---------------------------------
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