1811 ATLANTIC BEACH DR - FORM BOARD ELEV Foy , (?►k( ' QLL
A-14-411,4,'c
FORM BOARD ELEVATION CERTIFICATE
Duval County / Clay County
Left copy on site No box
Lot and Subdivision: -, y3 �T�aT,v/L ,c3 GG
DATE: // .. oz - i7 •
PERMIT
NUMBER: ! 0/49
ADDRESS: 0/8//
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REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: ) 2 . zo
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: )3 . o
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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Ellis&Associates Inc. Corporate
7064 Davis Creek Road,Jacksonville,FL 32256 P:(904)880-0960 F:(904)880-0970
03Group of Companies Branch Location:
Brunswick: 134 Newman Drive,Brunswick,GA 31520 P:(912)279-0085 F:(912)279-0086
Geotechnical•Construction Materials•Environmental•Facilities Daytona: 2706 S.Ridgewood Ave.,Suite 2 P:(386)944-9588 F:(386)944-9589
ellisassoc.com South Daytona,FL 32119
Report of In-Place Density (Asphalt or Soil) Tests or Coring for Thickness (Circle One)
Project: , • 1 i
Contractor: Z g,G, : Method: Work Order#: �I
Reported To: Location by: c — Project#: i v �.
Location: '.1 i 1 +4'1 l ��1c.J C tT,t t l.t> l . Report#:
Material: 44 Course: r • ,
Date Tested: I i Spec.Requirements: ., Gauge#:
Pass/ Elev/ Base/LR/ DryMax. % of Moist
Fail/ Location ( Depth/ Asphalt Dry Max
Retest Lift Thickness Density Density* Density
( ACV L . '7 �( /� : �1 ';`Th 7 `�
11/4i e
)er i t
*Source of Proctor (Project# and/or Work Order#)
P-Jest Meets Specification Requirements F-Test Fails To Meet Specification Requirements R- Retest
To Be Completed In Field Standby Approval
.
Employee Name
Superintendent Printed Name
Time
Start/Stop Travel Standby Job
Superintendent Signature
(Office use)
EA-03(rev.04/16) white copy-office use yellow copy.-personal use pink and goldenrod-client use Page_of