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FORM BOARD ELEVATION CERTIFICATE
Duval County / Clay County
Left copy on site No box
Lot and Subdivision: DoT= C S Ai L v4)\TT c E`er I} CC Z
DATE: 2- 6, •
PERMIT
NUMBER: 1 S V 2J 2v r
ADDRESS: \`7 o,N_, �
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: /t 16
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: •<ocS
�I
SURVEY COMPANY
NAME: Bartram Trail Surveying, Inc.
150,1 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
€ete
c��
(
Ellis&Associateslnc. Corporate
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. R'dgewood Ave.,Suite 2 P:(386)944-9588 F:(386)944-9589
ellisassoc.com South Daytona,FL 32119
Work Order#: Ca j' U 2 l-,
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#: ?2,4. ,
Subdivision: iN`1-L RE,.._!,- !i C l Reported to: Report#:
Unit or Parcel: Location By: c r -r- Gauge#: 1
Lot#Block: /(S Date Tested:
Contractor: Y +v��1 !TC
-1777-Z
Street Address: ,t-+,-»i 7, .t,r it u. `S, City: = ti
Method: `-ri .-•u Course: +-: , c L
• Material: F , i-,< - r'-, Specific Requirements: ;ç i.-
Pass/-� Elev/ Base/LR/
Fait/ Location Depth Asphalt/ Dry Max. Dry % of Max Moist
Retest /Lift-----Thickness Density Density* Density %
tk1fh ---k S 7
; t '1
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 In Field
�—" Standby Approval
Employee Name
Time �� ) Superintendent Printed Name
Start/Stop Travel Standby Job--------„
Superintendent Signature
l
1 (Office use)
EA-10(rev.04/16) white copy-office use yellow copy-personal use pink and goldenrod-client use
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