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HomeMy WebLinkAbout0146 RIVER ROAD - Health 146 RIVER ROAD, MARSTONS MILLS A=078 - 012 - I I I I i I i i I ` i O� aA ti' BARNSTABLE COUNTY x a DEPARTMENT OF HEALTH, HUMAN SERVICES AND THE ENVIRONMENT �w+ SUPERIOR COURTHOUSE s !�j BARNSTABLE,MASSACHUSETTS 02630 J Phone:(508)362.2511 Ezt 330 Public Health Administration 333 A►SS Environmental Health 383 Water Quality Analysis 337 Human Services 330 TDD 362-5885 LETTER OF LEAD ABATEMENT COMPLIANCE DATE: 1/10/95 Dear Mr. Elskamp This letter -is—to certify that I inspected your property located at 7-146 River Roadl , apartment no. , and relevant common areas, iii the City or Town of Mar-tons Mi`1'ls for lead abatement compliance on 1 /1Ws -- , and_on that date those surfaces cited in the initial inspection report of 1/R Z94 & 11/10/94 were found to be in compliance with Massachusetts General Laws, Chapter III, Section 197•, and 165 CMR 460.000 Regulations for Lead Poisoning Prevention and Control. Massachusetts • law does not require the abatement of all residential lead paint. The residential premises or dwelling unit and relevant common areas shall remain in compliance only as long as there continues to be no peeling, chipping or flaking lead paint or other accessible leaded materials and as long as coverings forming an effective barrier over such paint .or other leaded materials remain in place. See the reverse side of this letter for the location(s) of surfaces which were covered as an abatement method to achieve compliance, if applicable. Sincerely, izc9nector DPH Lic umber ne Crowley C2 9 INSPECTION AND ABATEMENT HISTORY i TanP rrnwl Py C 2829 Name & License Number of Inspector Who Performed Initial Inspection 1/10/95 Jane Crowley C2829 Date of Reoccupancy/Reinspection Name and License Number of (if applicable) Inspector Who Performed Reoccupancy/Reinspection Name(s) and License Number(s) of Department of Labor and Industry Authorized Deleading Contractors) Who Performed Abatement: .-.--John -Kovach - DC000561 LOLAC 03/30/93 AREAS WHERE LEAD PAINT OR OTHER LEADED MATERIAL HAS BEEN COVERED AS A LEAD ABATEMENT METHOD. ` INTERIOR Room No. (As.Indicated on Initial Inspection Report) Side Surface or Fixture Type of Covering EXTERIOR Side Surface or Fixture Type of Covering Commonwealth of Massachusetts Pg, � Of INSPECTOR/AGE C -CHILDHOOD LEAD POISONING METHOD USED Barnstable-Count ..He lth an PREVENTION PROGRAM ( NA 2S �a��7y Environmental epa ,m_ 305 SOUTH ST., JAMAICA PLAIN, MA Supeiior our use INSPECTION FORM Expiration -- -Barnstable,-MA 02630 /X-RAY Registration 1 C��� - f� FLUORESCENCE Model—A_j_1r3 Serial APT IT CITY------- ---- ------- -- '--... .----------._. I/I�A i(II I/ I 1 �1 .I I .I.�1�._J_-..I_1_._._I._._L��..�__J__.1 1 11.11,Il:n.• UU YV $r.■ 1 AS 1 NAM[ l FIRST NAME -- MM_ Burnt Gualdiari s Lam Name Parent/Guardians First Name _ 1.DWELL OWNER ` OWNS L/1_���I .Lel�1—I—I -y--� �C��I�,I ' I 2 DAY CC SC400LE OORN 1 UN(IS 3.OTHER V OR N I 1.SINGLE NO.OF ROOMS 2.2.4 APTS INCLUDE BATHROOMS 3.5 OR MORE H,7 BUT NOT HALLS --- -- LC arZ_ OWNER'S NAME: OWNER'S ADDRESS: , ► / �7— ------� /.�3-3 -- _--- ---------...__ REM- --- i =- 8� 0 -� � 7 ----- --- ARKS: Book No. . - -- - ------- ---- /,.c, U /-o 1. Page /-- --...-.__ _._.._— .-.---- - -- 0.6 Date recorded ..___.. ..___ .. .... . 1.Ol HER INSP.OAT E�--- --- 1 VICTIM 4 IIEI`AIR ```— ---- VIOLATION 2.PAR IIF(]. 5 VACANCY y Y OR N C� 3 HIGH INC IT.INSTIIUTION FLOOR J FLOOR I t �-�h�✓1 D Bi D B 0I Z ------ _ t A (STREET SIDE) A (STREET SIDE) Pb MORE THAN 1.2 rng/crn2 with x-ray fluorescence or positive with NazS is ILLEGAL. INSPECTOR -- -------- 1 IN COMM.IA/lf.F 11 ....------- --------- —'"" 1.IN COMPLIANCE RT:INSP.UA IT: 1, REINSP.DATE 1.IN COMPLIANCE REINSP.DALE 7,WORK IN PRO DRESS 7 WORK IN PROGRESS 2.WORK IN PROGRFSS —�� 3.NO WORK 3 NO WORK II•/ II/ 3 NO WORK REINSP DATE — -- I I IN COMPLIANCE REINSP.DATE — I. IN COMPLIANCE TINSfIE 1.IN COMPLIANCE 2.WORK IN PRO('iRESS 1T 2 WORN IN PRQ(iRFSS 2 WORK IN FRO(iRESS L3 NO WOIIKNO WORK 3.NO WORK - - . ' COMPLIANCE DATE - � � 16q INSPECTOR Pb = lead cov = covered Neg = Negative scr = scraped Pos = Positive rep replaced na = not accessible rev reversed cotTlp - e�F.Lnli�nce INSPECTORlAGENCY Commonwealth of Massachusetts Parnstahlac unw-ma, It"VkDHOOD LEAD POISONING PREVENTION PROGRAM Environmental Depai tment 305 South St., Jamalca Plaits, MA 02130 upenor ourt O se •INSPECTION FORM 630 1;13 ` of �- Registration f AN I /y) MUSS OF INSPECTION WF City ROOMyp n --- Comp Comp Comp Comp SIDE SOURCE Pb Loose Dare Method SIDE SOURCE Pb Loose Data Method Win ow Sill/Apron t Upper Walls Win ow Casing/{leader/Stops } Lewer- Laps - - -- ----- ----Will ow Sash/Mullions Chair Idol - ---- Ext for Sill/Parting bead area Baseboard �' Wi ow Sill/Apron Door t /o Door Casing Jamb Wi ow Casing/Header/Stops WI ow Sash/Mullions Door i - Ext rior Sill/Parting bead area Door Casing-Jamb 0. Exterior Side Sashes 1 Door h-D G ,Z Closet Walls Door Casing-Jamb v Closet Door-Interior Window Sill/Apron 1 Window Casing/Header/Stops Closet Casing-Jamb- 4Closet Baseboards . Window Sash/Mullions �Q - I �• �` t Exterior Sill/Parting bead area Closet Shelves } Floor Window Sill/Apron : Window Casing/Header/Stops 0, Ceiling 04- Window Sash/Mullions D r I I} Exterior Sill/Parting bead area e -- ---- --- t Window Sill/Apron OA Window Casing/Header/Stops Window Sash/Mullions Exterior Sill/Parting bead area ROOM # Windo Sill/Apron Upper Walls - Windo Casing/Header/Stops �QppRs Windo Sash/Mullions Owl, Extedo Sill/Parting bead area � Baseboard Exterior Side Sashes d Door G Closet Walls Door Casing-Jamb C Closet Door-Interior i p Door O S-f Closet Casing-Jamb n Door Casing-Jamb Closet Baseboards _ Door c_ Closet Shelves - - Door Casing-Jamb Floor �{ Window Sill/Apron Ceiling tT ----- "---- G - r? Window Casing/Header/Stops - Window Sash/Mullions_ r /o ? �- L Exterior Sill/Parting bead area D C Window Sill/Apron 0. G Window Casing/Header/Stops ,Z G Window Sash/Mullions ROOM Exterior S}IIlParting bead area n Will ow Si}I!A{xon Upper Walls ------on -- Wi ow Casing/Header/Stops Lower Vdalls Wit dow Sash/Mullions Chair rail -- — ----'--" - Ext rior Sill/Patting bead area Baseboard Door 0 Wi dow Sill/Apron - --� Wi slow Casing/Meader/Stops _ Door Casing-Jamb - ---- Wi dow Sash/Mullions Door Ex erior Sill/Parting bead area Door Casing-Jamb --'- — 1 Ober Exterior Side Sasher E{eset-1Alalls - D or Casing•Jamb -- -- Closet Door-lntorior Window Sill/Apron _ Closet Casing Jamb - Window Casing/Header/Stops (�• _- -- -- - Window Sash/Mullions r/0 'e Closet Baseboards Exterior Sash/Mullions bead area Closet Shelves 0. Window Sill/Apron floor Window Casing/Header/Stops Ceiling Window Sash/Mullions U Exterior Sill/Parting-bead area ✓ Pb MORE THAN 1.2 mg/Cm2 with x-ray fluorescence or positive with Na2S is ILLEGAL. ;EMARKS INSPECTOR Inspection Dare r ; -1011 INSPECTOR%AGENCY commonwealth.of Massachusetts Barnstable County Health an DHOOD LEAD POISONING PREVENTION PROGRAM Environmental Dep rt�rl � 305 South St., Jamaica Plain, MA 02130 .—SUpWiorEpv uSe "INSPECTION FORM Barnstable, MA 2630 of _ pg_ .� Reglat ration I Ca AUURESS OF INSPECTION Fy Y121A= y � CityROOM • Comp Comp SIDE SOURCE Pb Loose Cale° Meitoe SIDE SOURCE Pb Loose Dere eaernod AExte ll/Apron Upper Walls sing/Header;area Lovs►�IS ash/Mullions C-heirreih' l/Parting beaBaseboard ill/ApronDoor asing/HeaderDoor Casing-Jamb Door (� Q ash/Mullionsll/Parting bea Door Casing Jamb Exterior Side Sashes to. D m Closet Walls rCasing Closet Door-Interior 0 Window Sill/Apron Q 1 Window Casing/Header/Stops Closet Casing-Jamb B aseboards /1 j Window Sash/Mullions /0 9S P Closet i Exterior Sill/Parting bead area �(�C L 0 Closet Shelves 1 t ' Window Sill/Apron Floor Window Casing/Header/Stops Ceiling Window Sa9h/Mullions Exterior Sill/Parting bead area Win ow Sill/Apron Win ow Casing/Header/Stops Win ow Sash/Mullions ------------- Ext for Sill/Parting bead area ROOM r Wi ow Sill/Apron Wi ow Casing/Header/Stops Up r Wells Low r Walls Wi ow Sash/Mullions Chal rail Ext for Sill/Parting bead area �� Base oard Exterior Side Sashes / Door � Closet Walls Door Cesing=Jamb Closet Door-Interior Doo tp Closet Casing-Jamb oset Baseboards 0 L Dow Casing*- Cl Doo Closet Shelves Doo Casing-Jamb Floor Win ow Sill/Apron Ceiling Wln ow Casing/Header/Stops Wf ow Sash/Mullions Ext rior Sill/Parting bead area Wi dow Sill/Apron Wi dow Casing/Header/Stops Wi dow Sash/Mullions ; ROOM a Ex riot Sill/Parting bead area Upper Walls Wi dow Sill/Apron Wi dow Casing/Header/Stops LowerdMS W dow Sash/Mullions @#►aic.tail �. Ex riot Sill/Parting bead area Baseboard yJ idow Sill/Apron _ Door — Door Casing-Jamb D. 1N iduw Casing/Header/Stops Wi dow Sash/Mullions Door W Ex erior Sill/Parting bead area Door Casing-Jamb Ex erior Side Sashes Door Cl, set Walls Door Casing-Jamb (2 CI set Door Interior Window Sill/Apron Cl set Casing•Jamb Window Casino lHeeder/Stops Cl ds Window Sash/Mullions Exterior Sill/Parting bead areaWindow Sill/ApronWindow Casing/Header/Stops Window Sash/Mullions �•. �� Exterior Sill/Patting bead area f Pb MORE THAN 1.2 mg/cm 2 with x-ray fluorescence or.positive with Na,S is ILLEGAL. REMARKS �. INSPECTOR Inn Date T/7Mq INS PEcroR/AGENCY Commonwealth of Massachusetts =rvsn' OGRAM e County Heal h andC��IILDHOOD LEAD POISONING PREVENTIONEmental Depart a 305 South St., Jamaica Plain, MA 02130 a "INSPECTION FORM U Of Barnstable MA 02 30 q9 J yr ---------_ Registration I _-_5��.�p-e� - ---- APT./- M (� AODRE55 OF INSPECTION TI C(./s /��S / '/ZX- t � L� City F1 1- -4ale PANTRY Cemp Cemp KITCHEN Pb Loose Data nnetnoa comp Comp SIDE SOURCE Pb Loose Date Matltea -"- SIDE SOURCE - uppe Walls r Walls Upper Walls _�_ _Lowe --- �evver-V�affs _ - _Chair ail Base and Baseboard Door Door Door asing-Jamb Door casing-jamb I Door - Door Door sing-Jamb Door Casing-Jamb Windo Sill/Apron Door D Windo Casing/Header/Stops Door Casing-Jamb -46 Windo Sash/Mullions D or Exterio Sill/Parting bead area D or Casing-Jamb Exterio Side Sashes D or Upper abinets D or Casing-Jamb Upper abinets Walls D or Upper abinets Shelves D or Casing-Jamb Lower binets Window Sill/Apron Lower binets Walls Window Casing/Header/Stops 0. - Lower abinets Shelves �- Windo IhSasw Mullions Shelves - Exterior Sill/Parting bead area p Drawer ---- — Window Sill/Apron Floor. Window Casing/Header/Stops Ceiling Window Sash/Mullions 0. V° Exterior Sill/Parting bead area Window Sill/Apron b. CZ Window Casing/Header/Stops Window Sash/Mullions / Exterior Sill/Parting bead area S BATHROOM Exterior Side Sashes - Upper Cabinets ' ( Upper Walls Upper Cabinets Wall I Lower Walls Upper Cabinets Shelves Lower Cabinets B.asebeetd Lower Cabinets Walls p Door G' Lower Cabinets Shelves . Door Casing-Jamb Shelves Doer Drawers Dser-G_ b — Closet Walls Window Sill/Apron Closet_Door Interior Window Casing/Header/Stops 0' Closet Casing-Jamb Window Sash/Mullions d'U Closet Baseboards Exterior Sill/Parting bead area 0 i Closet Shelves Exterior Side Sashes Floor ' Upper Cabinets _ Ceiling Lower Cabinets Lower Cabinets Shel_ vex_•_ 0` — She ves, vl n �— Cloj at Walls — Q to S, 1 O Clo at Door Interior Clo at Casing-Jamb t -- Cl at Baseboards Cl at Shelves Floor Ceiling N 1.2 mg%cr►i z with X-ray 'fluorescence or positive with Na2S is ILLEGAL. ?' M0RE THA REMARKSiN,,tl�'( r, = 'w,9 do INSPECTOR C' Inspection Oale 51/i Toof :CEf 4IgSPECTOR/AGENCY Commonwealth'of Massachusetts �rnsfabre oun IMkl UDHOOD LEAD POISONING PREVENTION PROGRAM FnvirnnmF+nral Deoa tment 305 South St., Jamaica Plain, MA 02130 Superior Court House *INSPECTION FORM Barns2a 5V 630 — pg •� of — Registration/ C�� fJ - AD014ESS OF INSPECTION APT-f -_l_7-1 C�1-f-]. _01)HALL HALL c°"'l' c""'1' SIDE SOURCE Pb Loose c SIDE SOURCE Pb Loose Dole Mow,nl Dnlo Mouod Upper Walls Q, --- Upper Walls bower--Walls Lowes-W lls --- --- _-_ --- Ct"eir-rW Baseboard Baseboard I-.-._ Door -- - - -- � Door - J Door Casing-Jarnb Door Casing-Jamb _ - Door Door Casing-Jamb Door Casing Jamb -� Door J. Door Door Casing-Jamb ] JDC�asing mb _...-- D -- - - -- -- _.-_.._D -r Casing-Jamb - -- - Casing-Jamb - Wi idow Sill/Apron ow Sill/Apron - W'ulow Casing/Header/Stops- --- ---- - _ -- 9 - p - ndow Casing//Header/Sto s - W ulow SaSh/Mullions ndow Sash/Mullions _ - __- Ex riur Sill/Parting bead area -- --- E tenor Sill/Parting bead area Ex riur Side Sash E terior Side Sash i CI set Walls C set Walls .... ._.. ._._. __ .-.._...__.... .................... - -- ---------- --- --- eta Clc et Dool-Interior C set Door-Interior Clc et Casing-Jamb g- C set Casin Jamb - _ _-- - - Clc et Baseboards C set Baseboards Cl( et Shelves CI set Shelves - -_ --....._... Floor Floor l ---.... Floor ��_- - - --- ------- Cciliny-- - - ---- -- (V - Ceiling STAIRCASE c/ cl- &2 STAIRCASE -- t --- - -- Upper Walls ---- ---- S - upp Walls - Low Walls I Wall Casing Wall asing Chair rail Chair rail Treads ... . _.. _.-. Treactz ��. e Risers ---- - - -- -- - ----- - --- - Riser _:. -.._........ I Railing Cap Railil Cap--- - --- _.......... ...._....._.. I-landrails Han ails - --- -_-- - -- -_ - -_---,- 8"kws ws - Balu ters _------_-- _-- --- --_-.. Ne I Posts - -_ -- -_ Stringer Stri ger Base6eaws Basi boards (, Window Sill/Apron Win low Sill/Apron C Window Casing/Header/Stops Win low Casing/Header/Stops - L Window Sash/Mullions Window Sash/Mullions Exterior Sill/Paitiny bead area �� Exterior Sill/Parting bead area _ Exterior Side Sash Exterior Side Sash -- Door Door Door CasincJ•Jarnb 0, Door Casing-Jamb - ------ -- Door Door -- -- -Door_Casiny-Jamb Door Casing-Jamb _ -_.--- Coiling _- , ,p.--. _ —•T- Pb MORE THAN 1.2 mg/cm2 with x-ray fluorescence or positive with Na2S is ILLEGAL. REMARKS INSPECTOR Inspeclion Dare Y y INSPECTOR/AGENCY Commonwealth of Massachusetts arns a e Dun y eal th 6, LDHOOD LEAD POISONING PREVENTION PROGRAM nv ent 305 South St., Jamaica Plain, MA 02130 Superior Court Hou a "INSPECTION FORM -y Barnstable MA-M 30 qu9 Of Registration/ C—) -- APT.I AUUIII ti501 INSVI CI ION �1 y I I 1 I lI e e v-i DEG Uly EXTERIOR 'l — comp ramp SOURCE Comp comp SIDE SOURCE Pb Loose Data Pb Loose Method SIDE Data Method 0 Siding 0 tSiding, Cornerboards Co Cornerboards Door. 3 _ M/0 - 04 Door 1 Door Casin Jamb LDoor Casing/Jamb Threshold J'jl�' Threshold Door Door Casing/JambDoor Casing/Jamb Threshold t:V Threshold _ ( Window Sill. L)Yl1 t Aa,A. Nndow Sill - © 3 Window Casing Window Casing - C' ;Window Sash/Mullions r`>L ! 3 Window Sash/Mullions Window Sill Window Sill_ Window Casing —_ _ 2 Window Casing r � Window Saslt/Mullions /0 -1 2- Window Sash/Mullions -�— Window Sill Windo Sill Windo Casing Window Casing Windo Sash/Mullions Window Sash/Mullions Wind Sill Window Sill Wind Casing Window Casing Window Sash/Mullions Window Sash/Mullions Upper Trim O giin dCellar i,•dow Units s L1Cellar indow UnitssCellar indow Unitss Cellar Window Units Cellar Window Units Bulkl ad Bulkhead _ Fences Fenc s Foun lation — �► — d Foundation -- -- — at lop >; Pb MORE THAN 1.2 mg/cm2 with x-ray fluorescence or positive with Na2S is ILLEGAL. ; i REMARKS S;de G�JI LW � /'' o � (.� t / ,1 s INSPECTOR s,de. Inspection Data ylindays t oras /e,�t ,�i�h _F] K" INSPECTOR/AGENCY Commonwealth of.Massachusetts B_nstablP Coo tY e�hhlEbfiOOD LEAD POISONING PREVENTION PROGRAM Environmental De artment 305 South St., Jamaica Plain, MA 02130 -- --superior CourtHouse. *INSPECTION FORM Bar�stA 02630 qg / �f Registration / nrr - - - nUltRltiff ltl IN I'tC 1 1(1NGAfMG y � - E --- EXTERIOR _S� Vie- --- --- -- ----- ---co,�P cnntp --- Comp Comp SIDE SOURCE Pb Loose Data nnaa,od SIDE SOURCE _ Pb Loose Data Motrtod --- ----- -- Siding -- Sidiny ---- Dripboard ----..--1- — — _ _. Skirt _ _ _ _ Cornerboards o V rn- Coerboards -- _—_ D or _Do_or _ ------ — ` -T- D or Casing/Jamb Door Casing/Jamb _--_ — TI reshold - - Threshold or — Poor _ _ 1.= .- -- - � D or Casing/Jarnb Door sin /Ja�mb- _� f-' C` T eshold --- L Tiuesi uld-_v_ --- ` Q-- —� - Window Sill C' Window Sill /o/Q tNindow Casing �C. �.� Window Casing _ D , Vindow Sash/Mullions ' — Window Sash/Mullions �. Wit dow Sill Window Sill _— �..�-. ..__. ---- ----- Wi dow Casing ---------_-- Window Casing _ cQ__-- — Cy -.--- — Wi dow Sash/Mullions -- _ _C_ Window Sash/Mullions —— Wi dow Sill Jc " Window Sill - — _ Wii idow Casing Window Casing _. __—.—___-- -- Wi dow Sasli/Mullions Window Sash/Mullions Wi dow Sill �- --- Win w Sill -- -.-�---- Wi r dow Casing -- --Will( w Casing _ -- -- — _ -- Wi i dow Sash/Mullions -- Win( tw_Sash/Mullions _ Upper Trim ---- U�)N r Trim V' /..?1 S � Cellar Window Units Cellar Wi.dow Units Cellar Wi dow Units Cellar Wil dow Units ._.__.. ...__ .. _ Cellar Wi dow Units - Cellar Wir dow Units — _— Cellar Wi dow Units ---- Cellar Wi tdow Units -_-- -- - Bulkhea ------ - l3ulkhuad ---- --- - --- Fences - ------- — Fences — ----- Foundation - - - Foundation r -- --_. .__ —— -- --- _er '') � - -=- - - --- ----- — - ---- ----- - ,Pb MORE THAN 1.2 mg/cm2 with x-ray fluorescence or positive with. Na2S is ILLEGAL. REMARKS C S II�Q / U, illddw ofI S/ de— /j ��)d t� /A k1 { INSPECTOR rr �/V �i r/ `1 h / Inspection Date ,911 Town of Bdirnstable P# _s Department of hleal(h,Safety,and Environmental Services oftl+e Public Health Division Date $ 367 Main Street,I lyannis MA 02601 9ARNBTAar$ 19. rFDMtK�� DateSclfe'duled_ _ ( �{ qQ Time _3, Fee Pd. � y } i Soil`Suitability Assess»zent for• Selvage Disposal Performed By: �tR Qd 4 Witnessed By:V R ('l/ Yyn N /14h J L,OCA'TI0. & Ii NEItAL I IFOR1VtATIQN Location Address-' ` t- 3 w� Owner's,Name J 'Address 14,t, (ITc ,5 ` Assessor's Map/1 cel:. 7V10 Engineer's Name D un 6� e�J NEW CONSTRUCTION l' REPAIR_ Telephone N' Land Use Slopes(%) Surface Stones Distances from: Open Water Body R Possible Wet Area it Drinking Water Well tt -Drainage-Way.-_ R Property Line R Other n SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) #69 t.o � Z Parent material(geologic) Depth to Bedrock ^U Depth to Groundwater: Standing Water in I line: �O _ Weeping from Pit face A/U Estimated Seasonal Iligh Groundwater DT: It1VI1NATION FOIL.SASONAI,YIGt`VVATR TAI3L : . Method Used: C ............ Depth Observed standing in obs.hole: in. Depth to soil mottles: LO C� in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment R. -Index Well N___._._ Reading Date:_.__ Index W I level-_.__ Adj.factor Adj.Groundwater Level_ PERCt:LLATIQN TEST llttte i �l ime: d l Observation Hole N 2 _ ._. Timc at 9' Depth of Perc A rime at 6" , Start Pre-soak Time© /.-�� ` 't'� Time(9"-V) End Pre-soak Z W11N1 Rate Min./Inch / Site Suitability Assessment: Site Passed V Site failed: Additional Testing Needed(YIN) f Original: Public Health Division Observation hole 3' .'o Be Completed on Back j Cnnv- Annlirnnr . WE LION YTOLE LOG Depth from Soil llorizon Soil Texlure Soil Color Soil Other Surface(in.) (USDA) (Munsell) Molding (Structure,Stones,13oulderes. Coil siSlgIlt<X._lsSi[�YS�] z sly/ wo `. DEEP OBSERVATION 1OLE LOG Iiolc,i' t � Depth from Soil Horizon Soul Texlu`re Soil Color Soil Other Surface(in.) (USDA) (Munsell) Willing (Structure,Stoncs,Houldcres. DECY 013SCRVA'I'ION YIOC,L LOG Iolc# Depth from Soil Ilorizon Soil Texture Soil Color- Soil Other Surface(in.) (USDA)„ (Munsell) Willing (Structure,Sloucs,Bouldems. Consisiclicy.e GFRYCH DLEI' OISERVATION HOLE LOG Ilolu 1'!: Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mollling (Structure,Sloes,13oulderes. _ Sonsisignm-yyCi-t;lrcll_ Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes " Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally-occurring pervious material exist in all areas observer] throughout the area proposed for 1the soil absorption system? i If not, what is the depth of naturally occurring pervious material? r Certification-- // I certify that on "I (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was perfonned by me consistent with the required trait ing,expert'se and experience described in 310 CM 15.017. Signature 1 Date ✓ /(�