1883 ATLANTIC BEACH DR - FORM BOARD ELEV FORM BOARD ELEVATION CERTIFICATE
Duval County I Clay County/Nassau County
Left copy on site I No box
Lot/Subdivision: jc40 65 c_k4
DATE:
PERMIT
NUMBER: "A---
• ADDRESS: /04,_
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: kut)
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: R( ')\
SURVEY COMPANY NAME:
Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
i
l ti
Exi Ellis&Associates Inc. Corporate
7064 Davis Creek Road,Jacksonville,FL 32256 P:(904)880-0960 F:(904)880-0970
SEGroup 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
I 0 Y /fi'(,,,,��2 i' 1 ' for. Work Order#: .
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#: \.
Subdivision: - L -, - Reported to: Report#:
Unit or Parcel: Location By: Gauge#:
Lot#Block: 5 5' Contractor:
Date Tested: ,
Street Address: - t i City: --
Method: Course:
Material: Specific Requirements:
Pass/ Elev/ Base/LR/ Dry Max.Dry % of Max Moist
Fail/ Location Depth Asphalt/ Density Density* Density %
Retest /Lift Thickness
t, t. . I, 2
*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
--i 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
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