Soil Eval Form 2003 51e-
No. °�
FORM 11 - SOEL EVALUATOR FORM
Page 1 of 3
Date: 3/403
Comm onwealth of Massachusetts
, Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
P T LlicFtr .ct
Performed By:
Witnessed By:
Date: YAV0. 3
MAX/Ale S�/t ru df
Location Pones -
tax,
/Ll0%ct,f4-G4f S 4-e 2-f
ra$evVOt ✓, � .
t( irwt—eir
New Construction 0_ Repair ❑
T.loplato,
C. o lc Nor {G 4H h-Fon/
D Pia /0s L c sf
Nov 4cuu ,64J MA oiobo
Tel yi3 `587-/S70
Office Review .ter/
Published Soil Survey Available: No Yes ❑
Year Published Publication Scale
Drainage Class -. Soil Limitations
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit)
Landfonn
Soil Map Unit
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes ❑
Within 500 year flood boundary No ❑Yes ❑
Within 100 year flood boundary No ❑Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map(map unit)
Current Water Resource Conditions(USGS): Month
Range :Above Normal %Normal ['Below Normal ❑
Other References Reviewed:
DEP APPRO V®FORM-11/07/95
FORM 11 • SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. 004-1/12.44- 5110Wl ¢ to Ser Vol S 7.a
On-site Review
Deep Hole Number 3
Location (identify� on sip plan) _. .. ..
Land Use kl),00 G. G ltd-.. Slope (%) --0
Vegetation ?N, 7rge 5.
Landform /GTbiM% L
Lt',,t,- ----
Position on landscape (sketch on the back)
Distances from: ��
Open Water Body 44 0ir feet t
Possible Wet Area / _ feet 7L
Drinking Water Well -_ feet
Time:..gr/SG tN
Weather OVeie041' 304E
Surface Stones .. .L,-4..k..41- n" - 'NOW aver
i
Drainage way. ./0O feet
Property Line ? feet
Other ._... ..
DEEP OBSERVATION HOLE LOG`
Depth from
Surface(Inches)
Sail Horiaon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure,//Stones, Boulders,Consistency. %
0 - / 0,.
10 ' �5
.i5
rl
/4
TS
C
SA-nnd1*,'w
.Suti iocov
terse
G ���.
/00 3/ii
'°r 4�q
m '�Y
�.-
Loose in Cam. / �' " ' " 0
�,OOSe 104 z;1-15-171- /0/o 'v
loose if; V", �Ay1 uMA
a,/% 5-lDNesG Cn %!P5
.. ..
n AT n
wV ouAPnSN)fISPCNAL AREA
Parent Material(geologic)
5140-Lif oa,< tvaSl9
Ye "
7W'
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water:
DEP APPROVED FORM-11/01/95
Depdttoeadrock:
/n /,
Weeping from Pit Face: 78 "
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No AU N aW N S 1 nd'Sep v o 1 f
[� On-site Review
Deep Hole Number Date:_.3/L.. 03 Time: /O'.r3O Weather °VP✓L°L151
Location (identify onasite plan)
Land Use ,..w&cti'((.1-44-11 Slope (%) Surface Stones U-tf-_^-'
Vegetation _. ?'e -Y.V'Pi P ,
Landform ._. uu�v � P(4-4-471 . .. _ �...._,
Position on landscape (sketch on the back) - -..... ..
Distances from:
Open Water Body 40° - feet "1- Drainage way. . IOO feet
Possible Wet Area _./AO_, feet Property Line a feet
Drinking Water Well 400 ... feet+ Other
Parent Material(geologic) V aytt t d t 10110%
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water.
DEP APPROVED FORM-11/0!/95
DeptrtoBeckock:
f2-
Weeping from Pit Face: .71.4574/''
DEEP OBSERVATION HOLE LOG.
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munseli)
Soil
Melling
Other
(Structure,Stones,Boaulders,Consistency, %
O — !O "
k
to ° ie
/V '- 8b
i
?
(.° I
5''-'t Len'
y(0a.« mr, 06
Mail -
Coo pS
a 64-alai.
lotri ;ly
Joy y/y
0
—
2,s � 4�)
LOOSP {/'!/t all Le,
z.005-9
ioo 5e, hw, “. ,
Cobb (e5
w,pa 4_I p,et
5� w oil l�a,tgo'
�oN25
Do%sioNa3
5{Ne
r n
cw DPAPfllm nllPOSAI AHkA
Parent Material(geologic) V aytt t d t 10110%
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water.
DEP APPROVED FORM-11/0!/95
DeptrtoBeckock:
f2-
Weeping from Pit Face: .71.4574/''
FORM 11 - SOIL EVALUATOR FORM
p�
Page 3 of 3
/14 ( ' 25Cf .9/v 4)C/(,,,,+ �-may
Location Address or Lot No. �c�-6v U'r'"' " � G
Determination for Seasonal High Water Table
Method Used:
MDepth observed standing in observation hole 77 inches
Depth weeping from side of observation hole.. inches
❑ Depth to soil mottles _. _... 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? yes
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 42 - Y- 9y (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature � 3
�1�..r%'�' � Date 0
DU APPROVED FORM-11/01/95
FORM 12 - PERCOLATION TEST
Location Address or Lot No. Moccv±4i s-. 1��5?Y creJt /Pc
COMMONWEALTH OF MASSACHUSETTS
, Massachusetts
Percolation Test'
Date: 3,//
.-/C 3 Time: 9 — _._//,'30
Observation Hole #
Depth of Pere
9C/ /'
5a
Start Pre-soak
q ; 5 0 cep,,,-,
/0 f S a
End Pre-soak
n , Sry
// ; / ,
Time at 12"
(cam it
'r
// /7
Time at 9"
cr
/- „
// , -711
Time at 6"
5 orie. 6
7/ .13
Time 19"-6")
Rate Min./Inch
< a/11/
L v1 ✓WM/c.Pt
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area
Site Passed tg, Site Failed ❑
Performed By: ,k r T ,l/l C G v Lf
r n
Witnessed By: fj44. -1 ka- o-e--�-a-t.r. �. z°
Comments:
DEP APPROVED FORM-12r07ro5
7
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` � N MOUNTAIN STREET^ ge
7/A 1978 HAMPSHIRE ,COUNTY ALTERATION AND RELOCATION
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