1723 MARITIME OAK DR - DENSITY & FORM BOARD FORM BOARD ELEVATION CERTIFICATE
Duval County I Clay County/Nassau County
Left copy on site No box
Lot/Subdivision: Lo-r crL,
(1C
DATE: ( . 28 17
PERMIT
NUMBER: /(7 - SFW 38z�-o ►
ADDRESS: /7z3 MA.,e11 -1Me P\e- b2
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN :
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: /2
SURVEY COMPANY NAME:
Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
i
Ellis&Associates inc. Corporate
7064 Davis Creek Road,Jacksonville,FL 32256 P:(904)880-0960 F:(904)880-0970
iv, i
MGroup 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#: t`'.....:4
REPORT OF IN PLACE DENSITY RESIDENTIALProject#: LZ �"�`'
Subdivision: f--�l ...,t,-/,-4 S C ( Reported to: Report#:
Unit or Parcel: Location By: C L-1 Gauge#:
Date Tested: t` t
Lot#Block: 7 Contractor:
/12t t�r \' '' ` Jea-Ac \'r-- 4-
Street Address: City:
Method: 'V`-',,c. Course: F-' I L
Material: �; c- e
,1 � `"1� Specific Requirements: ' ��`'
Pass/ Elev/ Base/LR/ Dry Max.Dry % of Max Moist
Fail/ Location Depth Asphalt/ Density Density* Density °Io
Retest Thickness
L r'`-,4 N��' L - r7 /i3 .L. `2I5 --S / i
c--- ce/-i 7 cr.-L' - >2)-3- • -, -i. Li tv .-2 ; (?
E
r
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
j 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