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7054 Davis Creek Road,Jacksonville,FIL 32256 P:(904)880-0960 F:(904)SBO-0970
EllisUsseciateshm. car
!EGroup of Companies Branch Location:
Geolachrical a construction Materials I Environmental a Factlilies Banswc, 134 Nevonan Drive,Brunsivick,GA 31520 P:(912)279-0085 F:(912)2n-0086
Daytona: 2706 S.Ridgeivooil Ave.,Suite 2 P:(386)9�9538 F:(386)94�9589
ellisassoc.cont Soull,Daytona,FIL 32119
Work Order#: I I, N, -Z
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#: ?Z 2��
Subdivision: e �I C L Reported to: Report#:
Unit or Parcel: LOcation By: Gauge#:
Ut#/Blmk: 1 F4 Contractor: Dow Tested:
Street Address: �V< city:
Method: —,'— V Course:
Material: Specific Requirements: r
-PaSSL-x Elev/ BaseILR/ Dry Max.Dry % of Max Moist
Fail/ Location Depth Asphalt/ Density Density's Density %
Retest /Lift Thickness
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P-I�st Meets Specification Requirements F-Test Fails To Meet Specification Requirements R-Retest
To Be Completed In Field ---------------------------------
Standby Approval
Employee Name
Time Name
Superintendent Printed
Stan/Stop Travel Standby Job
Superintendent Signature
I---------------------------------
(Off.,-1)
EA-10(rev.0,1116) whirempy-officetor, WUW MPY-ffrioeal use pi�call gowni-client P., ( Of I
LFORM BOARD ELEVATION CERTIFICATE
Duv I County / Clay County
F--1 No box
[E-"Left copy on site
Lot and Subdivision: LoT- 112 AIL ANV=� MACH (D04T91j. (L U9
DATE: 2 / 1 / 17
PERMIT
NUMBER: Jb - �F�- 2,?o�
ADDRES
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: 90
ACTUAL ELEVATION OF FORM BOARD OR
GRADESTAKE:
SURVEY COMPANY
NAME: Bertram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR' (Party Chief)