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Home My WebLink About2000 Mar 21 - Soil Evaluator Forms, , FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 � G3 �= � �� ' � MAR 2 1 2U00 ; No. HEALTH DEPT. , , ____ _ 3-R-dU _.__ . � • __.. ----- _ � Commonwealth of Massachusetts I , Massachusetts ; Soil Stabilitv Assessment for On-site Sewage Disposal , - � ; Performed By: �I.1-uy ,�,��u�i � (�, 'z rt�x�P Date: 3-�-Op i Witnesses By. .�V ✓�N +FoNc sE /�( o{i- I � `°�'","°°`." �6 CKhn,Beft(L�y c�� ..�,�.w. � "" �C�42n�a�;�+�Po2l-, W� �-t. ' . T'k`K Pt+.aa.s�.) , ��a � New Construction � Repair ❑ TdqlezY i � O�ce Review , � Published Soil Survey Available: No � Yes � i Yeaz Published Publication Scale � , IG53 l� ZS � SoilMapUnit L�(G ; Drainage Class _�_ Soil Limitations _SE�=.7 f- Pao2 � ��Q ; Surficial Geologic RepoR Available: No � yes � ; Yeaz Published Publication Scale i Geologic Material (Map Unit) i Landform COMPLETED BY APPLCANTS SOIL EVALUATOR Flood Insurance Rate Map: Z 5 6V�S �� Z-D Above 500 yeaz flood boundary No QYes � w�ithin 500 year flood boundary No �Yes � Within 100 yeaz flood boundary No �Yes � Wetland Area: National Wetland Inventory Map (map unit) �1� Wetlands Conservancy Program Map(map unit) NJ�4 Current Water Resource Conditions (USGS): Month Range: Above Normal QNormal OBelow Normal � Other References Reviewed: � UE'P APPROVED PORM-12/U7/95 . i FORM 11 - SOIL EVALUATOR FORM � Page 2 of 3 L,ocation Addxess or Lot No. f$(� �q�� ,,q-N� VOT � On-site Review Deep Hole Number. � � Date: 3-C/-� Time: / S'OO Weather. suv �"� Location(Identify on site plan): Land Use: V��T LOT Slope(%): 0 -S`/e Surface Stones: NON$ Vegetation: (j2ip� � p�N Landform: Position on Landscape(sketch on the back): Distances ftom: Open Water Body: �� + feet Drainage way: ^- 2p` feet Possible Wet Area: 10p'+ feet Property Line: � O� feet Drinking Wffier Well: r�� feet Other. DEEP OBSERVATION HOLE LOG" Depth Bom Soii Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottlin9 (Structure,Stones,Bouiders,Consistency,% Gravep °-L � L�rr�R, Z-s g t.r�sR �ok�4ry G'�`'�� F�nR-8� S• 2�' �Jw LosA I�Y�25/� C�-M`'`�il'¢-� FR`�+BI,C- z �-s3 CI s'9""� ,sr�/� ru�s��/�se $3.. r32 GZ L65A �Di2;�a �rccn43�E�Gzhn.+v�+�1� � L . Parent Material(geologic) Depth to Bedrock: � Yj Z �+ ._. ____-.. _ _.._ __.__--_._. __. _. - .- _- ______ Depth to Groundwater Standing Water in the Hole �I�GNe - Weeping from Pit Face� /voNE Estimated Seasonal High Ground Watec � 3 L� � DEP APPROVCD FORM-12l07/95 FORM 1 I - SOIL EVALUATOR FORM Page 2 of 3 I,ocation Address or Lot No. ��+�_�� `v�--� On-site Review � Deep Hole Number: 7P- 2 Date: 3 -�1-O� Time: 1 S'�O Weather: S uhJ ' S 6"f' Location(Identify on site plan): Land Use: ✓ q�vT 1.oT Slope(%): (� 'S% Surface Stones: NONE Vegetation: i32if�l0�� Landform: I Position on Landscape(sketch on the back): Distances from: Open Water Bady: 1 Q7�; feet Drainage way: Z D�+ feet Possible Wet Area: I DD�t feet Property Line: 35� feet Drinking Water Well: N�h feet Other. DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Tezture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders,Consistency,°/a , Graveq 0- 3 � ts�rslGde� 3- ip � �CS<fLD IoyK'i��l �oN�' �,t.�t,vuL,Rf[ �FR-��31.� � �U- �f8 ' 6 w �s�9to ��2 s/e �.��u�trz. F2�� 4g -(o0 GI S�D •SY�Iy �Z �o�SE �op-13Z LoS�} I(��(R�IZ ('y��t�uuLfrrc. F-,e� A Parent Material(geologic) Depth to Bedrock .. �� .__..- _-_ __- -.._ _ ._.__--___-_ .___ .._ - __... Depth to Groundwater Standing Water in the Hole �/UC - Weeping from Pit Face: /v6 N� Estimated Seasonal High Ground Watec ��Z " ._— � DF,P APPROVED FORM- 12/07/95 � ' FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 I,ocation Address or Lot No. ( g j� �,q-�v_�L1, L✓�,vF, `,OT � On-site Review Deep Hole Number. j�" �j Date: ?,--�/(� Time: / S-'/�p Weather: s (,rv Sa° � Locatlon(Identlfy on site plan): Land Use: V�L�rV I LU i Slope(%): S�l 0�,, Surface Stones: �vo�i�f- Vegetation: �3(L_��P�� Landform: I Position on Landscape(sketch on the back): Distances from: Open Water Body: Z 00't feet Drainage way: 2 p'r feet Possible Wet Hrea: � (y�� Property Line: D'+- feet Drinking Water Well: N�A feet Other: DEEP OBSERVATION HOLE LOG" Depth from Soil Norizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA ) (Munsell) Mottling (Suucture,Stones,8oulders,Consistency,% Graveq �j—Ll � LYQ�SSI), ti-II 14 Gos,q � s��y �� ► � - 31 �w l.osH H'`tz�'� « t, 3 I - iZ6 C 5�,,,p 2.sY��,� ux�SE � Parent Matenal(geoloqic) r Depth to Bedrock: _- _—..- --- �L�f-. .. _ ._----- ... ---- Depth to Groundwater Stantling Water in the Hole /�.y�Alt _ Weeping from Pit Face: ��N� Estimated Seasonal High Ground Water: '7 6 �/ _ � DEP APPROVED FORM-12/07/95 . i . � , FORM 12 - PERCOLATION TEST Location Address or Lot No I�(� (�fL.A"�3F2�ZY—�--�^�E.--(�T� COMMONWEALTH OF MASSACHUSETTS ✓r y}JLryb�T�.} , Massachusetts Percolation Test * Date: .� _q,� Time: � S: av Observation Hole# Depth of Perc �3- �-/ Start Pre-soak �y.'U 5 End Pre-soak l�l: ZD Time at 12" ry' Zp Time at 9" ! �!-. 2Z- �6 Time at 6" � �� .Ly' sZ Time (9"-6") Z � 3b Rate Min./Inch i �� ` ".l i Ncrf "` Minimum of 1 percolation test must be performed in the primary area AND reserve area. Site Passed � Site Failed � Performed By: �B WS -- 5�_ _�SS_�,�ct�____ Witnessed By: �i�b��vE_ 5� _ (SOt�,_ Comments: � uFr nrrHov��:u F�okna-izion�s FORM 11 - SOIL EVALUATOR FORM , Page 3 of 3 Location Addre$s ot Lot No. � gb ��gq�Y L.4� � 0� , Determination for Seasonal Kigh Water Table ! Method Used: i : 1� � Depth Observed standing in observation hole inches � Depth weeping from side of observation hole inches � Depth to soil mottles inches []'Ground water adjustmenf feet Index Well Number Reading Date Index Well Levei � Ad ustment Factor � 1 Adjusted Ground Water Level � y(, " � De�th to Naturallv Occurrina Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? � If not, what is the depth of naturally occurring pervious material? �C� I Certification I certify that on � � �q (date) I have passed the soil evaluator examination iapproved by the ep rtment of Environmental Protection and that the above analysis was perfoRned by me consistent with the required training, expertise and experience � described in 310 CMR 15.017. Signature ,�- Date 3-g-� � DEP APPROVED FORM-Iy07/q$ � C7V �+ \ . 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