1602 MARITIME OAK DR - FORM BOARD FORM BOARD ELEVATION CERTIFICATE
Duval County / Clay County/Nassau County
Left copy on site J No box
Lot/Subdivision: Lok \'Z5 F (3,C („h„) CSL b
Cyan;
DATE: `� \ 3)37
PERMIT
NUMBER: Mk
ADDRESS:
DDnEJJ. A/fr-
REQUIRED
SLAB ELEVATION ON CITY
APPROVED SITE PLAN : ) , SO
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE:
SURVEY COMPANY NAME:
Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
I
Exi Corporate
Ellis&Associates Inc. 7064 Davis Creek 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
Work Order#: -� 7q
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#: R `.
Subdivision: P' ' L ` i-1 di ( ( Reported to: Report#:
Unit or Parcel: Location By: C( "7 Gauge#: .)
Lot#Block: lit Contractor: \-2 '`..) .'"C?c.'`..**
Date Tested: II - /429- s 7
Street Address: 11,,,,%::::7 ,ueis12 ti/ L-'C �; City: % . s-1 C P
-
Method: — Course: ' ' %-
Material: Ac,,, .`f Specific Requirements: '1-C `,'
Pass/ Elev/ Base/LR/ Dry Max. Dry % of Max Moist
Fail/ Location Depth Asphalt/ Density Density* Density %
Retest /Lift" Thickness
x i/(,v ( , „,vC.q �. • 1-2 2, , /`d3 .L.- `75 -t( - z
t /r --TL `�•`r . / lG -ki
r-
*Source of Proctor (Project#and/or Work Order#)
'J -Test Meets Specification Requirements F- Test Fails To Meet Specification Requirements R- Retest
To Be Completed In Field
-� Standby Approval
Employee Name
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