1817 ATLANTIC BEACH DR - FORM BOARD ELEV b t
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FORM BOARD ELEVATION CERTIFICATE
Duval County / Clay County
Left copy on site No box
Lot and Subdivision: Li ,�T�w ,., ;�f H� N
DATE: oa-_ tti_ / 8
PERMIT
NUMBER: )7- 0x"
ADDRESS: 4/7 //TSN-r-P 136-n-«r DZ
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: )/. 90
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: a 90
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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.11111111110
Jacksonville
7064 Davis Creek Road,Jacksonville,FL 32256 P:(904)880-0960 F:(904)880-0970
_Ers
Brunswick
134 Newman Drive,Brunswick,GA 31520 P:(912)279-0085 F:(912)279-0086
ecslimited.com
Work Order#:
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#:
Subdivision: - - Reported to: Report#:
Unit or Parcel: Location By: Gauge#:
Lot#/Block: (11) Contractor:'t • Date Tested:
Street Address: ' City: ti
Method: Course: 1✓
Material: Specific Requirements:
Pass/ Elev/ Base/LR/ Dry Max.Dry % of Max Moist
Fail/ Location Depth Asphalt/ Density Density* Density
Retest /Lift Thickness
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*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
Time Superintendent Printed Name
Start/Stop Travel Standby Job
Superintendent Signature
(Office use)
ECS-I0(rev.01/18) white copy-office use yellow copy-personal use pink and goldenrod-client use
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