160 Soil Eval Forms 2004 No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date:
Commonwealth of Massachusetts
/✓0R*/4 Awl Pro AK Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By:
Witnessed By:
b4N/ �
1w QrJ
/114-1-4 I cut--
Date: ,07804
Imiun Addrafi-Nok I+ e'l farad 4"2 opA
Dtk - ley 2D.
New Construction ❑ Repair 1!
— an,,) r _ 7 0i o(e/
4/3 _ st*- 7? 96
Office Review
Published Soil Survey Available: No ❑ Yes ❑
Year Published
Drainage Class
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map: �!
Above 500 year flood boundary No XYes
Within 500 year flood boundary No ❑Yes ❑l
�
Within 100 year flood boundary No El Yes St
Wetland Area: / `
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
n 0
Current Water Resource Conditions(USGS): Month ��, I - %60
Range :Above Normal ❑Normal pBelow Normal ❑
Other References Reviewed:
Publication Scale
Soil Limitations
Soil Map Unit
DEP APPROVED FORM-12/07/95
Location Address or Lot No.
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
NIi pyvIl 744ic Pater
On-site Review
�14_1tM 2- ✓ /z/" Zf 00 Weather
Deep Hole Number Date: Q Time:
Location (identify on site plan) ' l
Land Use ..LAW -- Slope 1%1 j 70 Surface Stones /t/ e 0 r
Vegetation 5"02.55
Landform _. L.00hPL-/r✓
Position on landscape (sketch on the back)
Distances from:
Open Water Body>kit) feet Drainage way >j/pe feet
Possible Wet Area >/pp feet Property Line 30 1////feet
Drinking Water Well 1/06 feet Other
DEEP OBSERVATION HOLE LOG°
Depth Rom
Surface(Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure,Stones, Boulders, Consistency, %
0 —1r
36 /2c
4
PSL
VFst
rP
IN Z3/3
2-534.96 2-534.96
'—
-
1 �Graaveil
.147P^ l ,.J/� idree-
J
S ) .r-tlssrve--
-L
SA-ri6
-
Parent Material(geologic) HIItAt/IAL- 66P05- tY4
Depth to Groundwater Standing Water in the Hole?/0 2/ %/Q
Estimated Seasonal High Ground Water: /2.01 /ZD
DEP APPROVED FORM-12101195
DepthtoBedrock: %/O /Cl
Weeping from Pit Face:1% /0 r
FORM 12 - PERCOLATION TEST
Location Address or Lot No. /t/ ibtfro%DN AI kPd R-
COMMONWEALTH OF MASSACHUSETTS
AktillAfrird, Massachusetts
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed
Site Failed ❑
Performed By: !Js}nb6 Ni-Tz- &
Witnessed By. L tAjeS1SC Atd-Th 1 Et,'
Comments:
DEP APPROVED FORM-11/61/95
Percolation Test"
Date:
j0. ?�$ 7p
Time:. too
Observation Hole #
!P -1
P.2
Depth of Perc
i1_g tr
49 f
Start Pre-soak
.2' 33
21 3C
End Pre-soak
z , 1-8
1.5-0
Time at 12"
2---
VC°
Timeat9"
3 (/O
3. 0.2-
Time at 6'
3 ' 3/
3 ; Z�
Time (9"-6")
it //(D�,
�.A
Z x/27 -
Rate Min./Inch
F y�/�
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed
Site Failed ❑
Performed By: !Js}nb6 Ni-Tz- &
Witnessed By. L tAjeS1SC Atd-Th 1 Et,'
Comments:
DEP APPROVED FORM-11/61/95
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date:
Commonwealth of Massachusetts
A/ {inlY)PTp„/ , Massachusetts
,Soil Suitability Assessment for On-site Sewage Disposal
Performed By
Witnessed By
w[, it/rct5c
GYWeT 7 /11 4-r/ft E0_,
Date
m,wn AdthS1 a Rest pobA/ i4-r2Fc e c
OGD CRY /16,
New Construction ❑ Repair Q�1
Lac,
Office Review
Published Soil Survey Available: No E
Year Published
Drainage Class
Surficial Geologic Report Available: No ❑ Yes ❑
a,•��•>u".."Dm. A&t h - „
” At&per
., Ro . 130K 7-72-1
n,a- of 06
40 -s-s4--fge
Yes E
Publication Scale
Soil Limitations
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map: ,,��{{
Above 500 year flood boundary No PF ,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 OCT.
Range :Above Normal ❑Normal elow Normal ❑
Other References Reviewed:
Soil Map Unit
DEP APPROVED FOR-N1-12/07195
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No Nt 2_173¢ /'VlV A-WOOsr
On-site Review
Deep Hole Number Date: w of Time: 2` CD Weather
Location (identify o9 site plan)
Land Use vim, ��
."- "
Slope (%) Surface Stones /v , 0 •
Vegetation Q F
Landform ^rtflp P ,/
Position on landscape (sketch on the back)
Distances from:
Open Water Body-7/00 feet Drainage way›"CR1 feet
Possible Wet Area -Q0 feet Property Line SO feet
Drinking Water Weil 7.019 feet Other
DEEP OBSERVATION HOLE LOG.
Depth from
Surface(Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munselll
Soil
Mottling
Other
(Structure,Stones, Boulders, Consistency, %
GraveII
40
ile -3Z
32 /2o
4
g
C."
r
vg(--
fu/$G inch j^
�s
2sy -
2s(/S3
✓S
j / e
Si'v"2---
.PaI
weaL) s/-7‘ ,,a.-�
—
—
P3
Sq-,MS
as 1
a///// /S/O
Parent Materiel(geologiq /�{�(✓l f}L dole/ OthtoBedrock: �/O
r .>/Or Weeping from Pit Face: >/O'/>/0 /
Depth to Groundwater: Startling Water in the Hole: /� / g
Estimated Seasonal High Ground Water: /ZD t r SJ'LO
DEP APPROVED FORM-11/07/95
Location Address or Lot No.
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Determination for Seasonal High Water Table
Method Used: IVQf Qe6�dG ( 2-0 (C
❑ Depth observed standing in observation hole........ ...... inches
❑ Depth weeping from side of observation hole .. inches
❑ Depth to soil mottles inches
❑ Ground water adjustment feet
Index Well Number
Adjustment factor
Reading Date
Index well level
Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring
observed throughout the area proposed for the
If not, what is the depth of naturally occurring
Certification
pervious material exist in all areas
soil absorption system? AFC
pervious material? _ /-
1 certify that on (date) 1 have passed the soil evaluator examination
approved by the D partment of Environmental Protection and that the above analysis
was described in performed d by me 15.017.
n / "z`with the required training, expertise and experience
Signature g/tr) � Pate /Z-A01
DEP APPROVED FORM-12/07/95
Location Address or Lot No
FORM 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
Otri-211)-wp-oil , Massachusetts
Percolation Test`
Date: I0("z8( l Time., 0 1_
111
Observation Hole #
p^3
n -4
Yfg
Depth of Perc
1-91(
/o
//
Start Pre-soak
3_1 4
Tv
End Pre-soak
x, : 22
3%zs
Time at 12"
3 .z-2
3t! 25--
Timeat9"
3 \ 5 f
I
3 :SS
Time at 6"
/I 1 t )
`
5 Jo
Time (9"-6")
4o
?,,.-
Rate Min./Inch
//
2
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed
Performed By:
Witnessed By:
Comments:
1
Site Failed ❑
1>A-ilr` A-{. titT scl
aA a-ce /4 A AUec c-
DEP APPROVED FORM-12/07/95