1240 Seminole Rd RES19-0102 Form Board/Density I
FORM BOARD ELEVATION CERTIFICATE
Duval County / Clay County
Left copy on site
No box
Lot and Subdivision: LUT B S-,(Uc, A46 1y c
DATE: 7,/it it0
PERMIT n6,01-
NUMBER: �S
ADDRESS: \,7j- 5 ;/\ kt
REQUIRED SLAB ELEVATION ON CITY
APPROVED SITE PLAN: t,75
ACTUAL ELEVATION OF FORM BOARD OR
GRADE STAKE: 1 $q
SURVEY COMPANY
NAME: Bartram Trail Surveying, Inc.
1501 CR 315, Suite 106
Green Cove Springs, FL 32043
SIGNATURE OF SURVEYOR: (Party Chief)
0
JacksorVIe
7064 Dave Creek Road,Jacksonville,FL 32256 P: (904)880-0960 F:(904)880-0970
Brunswick
134 Newman Drive, Brunswick,GA 31520 P:(912)279-0085 F:(912)279-0086
ecslimited.com
Report of In-Place Density (Asphalt or Soil) Tests or Coring for Thickness (Circle One)
Project:
Contractor: Method: Work Order#:
Reported To: Location by: Project#: ,
Location: Report#:
Material: Course:
Date Tested: Spec. Requirements: Gauge#:
Pass/ Elev/ Base/LR/ Max. % of
Fail/ Location Depth/ Asphalt Dry Dry Max Mo ist
Retest Lift Thickness Density Density* Density �O
Uri , d VD, 0 11- 3 7
) Q( - I 11- L 17 -7) 4g.
*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
Superintendent Printed Name
Time
Start/Stop Travel Standby Job
Superintendent Signature
(Office use)
ECS-03(rev.01/18) white copy-office use yellow copy-personal use pink and goldenrod-client use Page_of