41 Septic Perc Test 2004 • ALAN E. wEls.M
licensed Site Professional
Registered Sanitarian
Hydrogen[Nisi
President
9 Old Enfield Rd.
Icr cnoum, MA 01007
3)323-5957& 323-4916(36694)
-Subsurface Investigations
•2IE She Investigations
•Pollution Remcdiabon
-Pearnlation Tests and
Septic Designs
FORM 11 - SOIL EVALUATOR FORM
Page I of 3
Commonwealth of Massachusetts
Aft Hnw fc J , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Date:
•
Performed By: �•�1-�PtSStn�
Witnessed By: "L�.��'E. d" 4 NIIE�
Date: *H/23 /ay
>m Rob
Lo ZS! d715f,Pef/41
Mc ^'ikn,�c�0oh•J
J ew construction NI eoair D
0.m Wn.
A6YV�,aM
T LONER
I P ilea in
°Mee Review
Published Soil Survey Available: No I I Yes LJ
Year Published Publication Scale
Drainage Class Soil Limitations
Surficial Geologic Report Available: No 1 I Yes D
Year Published Publication Scale
Geologic Material (Map Unit)
Landfom
Flood Insuance Rate Map:
Above 500 year flood boundary No ❑yes
Soil Map Unit
Within 500 year flood boundary No Yes Rill
Within 100 year flood boundary, No I Yes LJ -5,4Jc.t; cc 4p - 5.4ar r CiQR%•
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Condi - ns (USGS): Month
Range :Above Normal Normal I Belt^i Normal
Other References Reviewed:
DEP APPROVED FOWL • v 007/9=
Location Address or Lot No. La (roS5p 44L•
117tH=SGIL EVA-IMATOR-FORM
Page 2 of 3
On-site Review
Deep Hole Number tZ_. Date: !r/73 Jo.f
Location (identify on site plan) . .,_..._.. _.
Land Use N1Zi1415 . Slope (%) /
Vegetation Ira 55
Landform
Position on landscape (sketch on the back) ...
Distances from:
Open Water Body ion 'Y feet
Possible Wet Area :00 'f feet
Drinking Water Well loo 'i feet
Time 2 '.no Weather SL t/ •
Surface Stones No f
Drainage way .,JV feet
Property Line /00 'f feet
Other ... ...
DEEP OBSERVATION HOLE LOG•
Depth from
Surace(Inches)
Soil Horizon
Soil Recmre
(USDA)
Soil Color
Nun-seal
0 (Z
'z-36
36 ' 15D '
Ao
C ,
Soil Caner
Marling (Structure,Stones. Boulders,Consistency, %
Graved
A/o/
o b5,
V {„1c 5aie•
Th461e Laos
f: SAAJd:
MINIMUM OF 2 HOlcc r16OUIHcD At
Parent Material(geologic/ J'l f ,
VERY PHOPOScD DISPOSAL AAeg J.C5�
DeptlnoBedrock: / � t\
Death to Groundwater: Standing Water in the Hole: C - Weeping from Pit Face:
Estimated Seasonal High Ground Water: /Yo/
/2 Z 'r
DEP APPROVED FOR1t-32/0:195
Location Address or Lot No. .=S Cross
FORM 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
I„Vy +cwliuv , Massachusetts
Percolation Test*
Date: ( � IZ 3 I o'/
Observation Hole #
Depth of Perc
Start Pre-soak
End Pre-soak
Time at 12"
Time at 9
Time at 6"
Time (9"-6"1
Rate Min./Inch
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area
Site Passed Site Failed—-11---
Performed By:
Witnessed By:
Comments:
a i;ct-.
DEP APPROVED FORM-12/07/95
FORM 11 -SOIL=LVALUATOR FORM
Page 3 of 3
Location Address or Lot No. C rostPe'4U-, R
Determination for Seasonal High Water Table
Method Used:
Depth observed standing in observation hole..... inches
U Depth weeping from side of observation hole.. inches
Depth to soil mottles a.; inches
Ground water adjustment feet
Index Well Number ___.....
Reading Date __-......... Index well level
Adjustment factor Adjusted ground water level
Depth of Naturally Occurring 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? 7 f"..1)
If not, what is the depth of naturally occurring pervious material? --
• Certification
I certify that on ;6/yS (date) I have passed the soil evaluator examination
approved by theD partme�nt of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.012./
_Signature_..
DEP APPROVED FORM-13107/95
--- Date
-