1618 Atlantic Beach Dr form board elevation certificate 1
FORINT BOARD ELEVATION CERTIFICATE
Duval County / Clay County
Left copy on site No box
Lot/Subdivision: r<, ATL-��Tl�. +3� �r! ��� ..►�z,/ �� �E3
DATE: ,.-7
PERM1T
NUMBER: -7 - C-50ew54
ADDRESS:
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN : !--,- ; L_'
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: 4z . 3z
SURVEY COMPANY NAME:
Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
Ellis&Associates IIIc. Corporate ( ) ( )
1-5,MrAl
7064 Davis geek Road,Jacksonville FL 32256 P: 904 880-0960 F: 904 880-0970
.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
Sca h P)-e a S Work Order#: 117�9 3 t;
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#: 223o(r
Subdivision: A41onhc 63 rh Cc. Reported to: 121 "er<,kCI C /-i,-,mwC- Report#:
Unit or Parcel: Location By: Gauge#: 3 a
Lot#Block: Contractor:
Date Tested: t CJ t c; /17
Street Address: _ I U 1 S 1a}lo,Ae c Fct-e r h -Dr, City:
Method: f,t'c l E n d q eacjcE Course: I Ii
Material: t,<< n <. Specific Requirements: /<,
Pass/ Elev/ Base/LR/ Dry Max.Dry % of Max Moist
Fail/ Location Depth Asphalt/ Density Density* Density %
Retest /Lift Thickness
N Yes
-rE l/-1 ' 03• 1`. 3y
' X7.3
*Source of Proctor (Project#and/or Work Order#) i 159e)!F<
P- Test Meets Specification Requirements F- Test Fails To Meet Specification Requirements R- Retest
To Be Completed In Field
Employee Name Se r e .1 y !�►,� Standby Approval
t,
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