1735 19-0044 Form Board Cert/Density Report FORM BOARD ELEVATION CERTIFICATE
Duval County / Clay County
EAI�Left copy on site F� No box
Lot and Subdivision: Go>- 9s .6tsZ�>c
DATE:
PERMIT
NUMBER: /a ov vy
ADDRESS: i�af rri- �.> o✓.� of
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: i/• y�
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: i z• 3Z
SURVEY COMPANY
NAME: Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief) 4
9
Jacksonville
C 0 7064 Davis Creek Road,Jacksonville,FL 32256 P:(904)880-0960 F:(904)880-0970
E 194 Newl an Drive,Brunswick,GA 31520 P:(912)279-0085 F:(912)279-008fi
urswit
ecslimited.com
Work Order#:
REPORT OF IN PLACE DENSITY RESIDENTIAL Project#:
Subdivision: - " L k Reported to: Report#:
Unit or Parcel: '- Location By: I - Gauge#:
Date Tested:
Lot#Block: Contractor:
Street Address: City: "
Method: - Course:
Material: - Specific Requirements: '
Pass/ Elev/ Base/LR/ Dry Max.Dry %ot Max Moist
Fait/ Location epth, Asphalt/ Density Density* Density %
Retest /LW Thickness
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*Source of Proctor(Project#and/or Work Order#)
P-Test Meets Specification Requirements F-Test Falls To Meet Specification Requirements R-Retest
To Be Completed In Field ---------------------------------
Staridby Approval
Employee Name
Time Superintendent Printed Name
Start/Soup Travel Sumdb Job
Superintendent Signature
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