589 Coastal Oak Ln slab inspection & form board elevation certificate Corporate
Ellis&Associates IIIc. 7064 Davis Creek Road,Jeckaorrvilie,FL 32256 P:(904)880-0960 F:(904)880-0970
Group of Companies Brancb location:
Geotechnical•Construction Matenals•EmnonmeMal a Facilities Brunswick: 134 Nearnan Drive,Bmnswck,GA 31520 P:(912)279-0085 R(912)279-0086
Daytona: 27M S.Ridgewood Ave.,sure 2 P:(366)944-9566 F:(386)944-9569
ellisassoc.com South Daytona,FL 32119
Work Order#: /zY
REPORT OF IN PLACE �
`Xa` E DENSITY RESIDENTIAL Project#: z 2 k�
Subdivision: l-"(. 10 Reported to: Report#:
Unit or Parcel: Location By: Gauge#: I
Date Tested:
Lot#Block: `l Contractor
Street Address: C` ti C .i 5"Ir'\ vAtcS Cr4i City: `NP`c
Method �-t ` Course: F It t
Material: fKf ice L`z-j Specific Requirements: `YC
Pass) . Elev/ Base/LR/ Dry Max.Dry % of Max Moist
Fait/ Location Depth sphalt/ Density DenDensity %
Retest hickness sity*
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i CCtv;e�t
*Source o roctor(Project#and/or Work Order#)
P• t Meets Specification Requirements F-Test Fails To Meet Specification Requirements R-Retest
To Be Completed to Field
-_. ----Standby Approval
Employee Name
Time Superintendent Printed Name
Start/Stop Travel Standby Job
Superintendent Signature
--------------------------------
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FORM BOARD ELEVATION CERTIFICATE
Left copy on site F-1 No box
Lot: 0
DATE: 3- 9 -7
PERMIT
NUMBER: /7 - S F2 _ 3o4 -7
ADDRESS:
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: /s_w
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: /3-k
SURVEY COMPANY
NAME: Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
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