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HomeMy WebLinkAbout0300 SMOKE VALLEY ROAD - Health L SMOKE VALLEY ROAD !7'`097001 Mgrsr�ns� Y TOWN OF BARNSTABLE LOCATION,— I44" —�"SEWA. VII.LAGE ;% SE OR'S MAPS T O 9 7_©�l INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by % ���r�,�as ��1' �l 13v1t4����v►� �a 8�Noose&IIA I k cr CAS a067 _SM C> e . v /100AeZ� N" U `7 Feed 6, BOARD OF HEALTH I c# TOWN OF BARNSTABLE 5/7I1B 01ppYication _for 39ell ConfStruction Permit Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at: Location-Addresi Assessors Map and Parcel So �w C ce 11 aS "bo os Ile Owner —7 Address /t 9 -mwAP-=s 1144- 0 a 4- V Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well 0't 6aTo,u o^j Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Comjliance as been issued by the.Board of Health. Signed ���j/ Sl Z/�8 Date 32a--z=::�> Application Approve By Date Application Disapproved for the following reasons: \ a� Date Permit No. \,, ld,�n 144 Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(q, Altered( ), or Repaired( ) by tOCGaM� �sg J&S 8 Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Vrot tion Regulation as described in the application for Well Construction Permit No.y 9t4"d 1 Dated 15 ¢ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Vern Construction Permit No. C I cl Fee Permission is hereby granted to r-jn,c l Installer to Construct(a, Alter( ), //oa�r Repair( an individual well at: No. 3crs Maklr Or (1, /�cI 6 f/t�l r Street as shown on the application for a Well Construction Permit No. C LSi `- C,) Dated Date �� �- Approved B • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617.292.55 g WILLIAM F.WELD c) NfCE r TRUD1'CGovernorJ Governor olvIr �► Secre i � ta ARGEO PAUL CELLUCCI �� -( S 1997D B.STRUI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE I FOIITftop Commissior. PART A H�[p ABA CCE�RTTIIFICATION Property Address:300 Smoke Valley Road 'dress of Owner: Date of lnspection6/1 1 /97 (If different) S Z Name of Inspector: Joseph P.Macomber JR. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J. P.Macomber & Son Inc . Mailing Address: BOX 66 Telephone Number:( enterville�MasS 02632 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Yse Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails zv Inspector's Signature: ✓ Date: 617�4 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system ownei and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: ,4)d One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, of the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Fay 1 of 10 DEP on the World Wide Web: hnp://www.magnet.state.ma.us/dep Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Smoke Valley Road Osterville ,Mass . Owner: Coolidge Date of Inspection: 6/1 1 /97 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced J_)j) The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: IVO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 1111 Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. ,00 The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER Az?� 1 . If The well has not been tested in the last year . We would recommend the well be tested. For: Coliform bacteria 2.Volatile organic compounds . 3 .ammonia nitrogen.. 4. Nitrate nitrogen. is equal to or less than 5 parts per million. Forms 2 Pages 2A & 2B (revised 04/25/97) Page 2 of 10 - of g,j BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE • BARNSTABLE, MASSACHUSETTS 02630 �A Be PHONE:362-251 1 EXT 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. Remove strainer or aerator from the end of the faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not fill ottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or any- thing else. 5. Fill out the reverse side. The laboratory requires accurate and complete informa- tion. The person filling the bottle must sign the form. 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, and nitrate) is $25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday-Thursday from 8:00 to 4:00. They must be deliv- ered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Please be prepared to locate the house on the maps at the laboratory. 9. Problems with town waters must be handles through the town water departments. 10.Completion of tests and results takes 7-10 days. Results will be sent in the mail. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS. THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCU- RATELY PERFORMED. PLEASE COMPLETE REVERSE SIDE OF FORM PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE'COMPLETING THIS FORM BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT 362-2511 X 337 DRINKIIVG WATER ANALYSIS LABORATORY SHEET Name Sampling Date: Time: Mailing Address: Sample Location: (Street or Box) (Street) (Town or City) (State) (Zip) (Town) Telephone: Year House was Built: Bottle Identification Number: Well Depth Feet (Taken from Bottle) Reason for testing (Check one): ❑ suspect a problem ❑ required by DEgE ❑ for information only ❑ new well real estate transaction* -Cr other: _ Note': Some banks and mortgage companies may require additional testing which costs more and requires more water. Check with Lab before bringing in the sample. Distance of supply from possible contamination sources (check all that apply): septic tank / cesspool _ feet ❑ farm feet ❑ salted highway feet ❑ buried fuel tank feet Cl land fill feet ❑ other feet Treatment used: ❑ none ❑ water softener Cl filter SIGNATURE OF SAMPLE COLLECTOR Cl Well Driller ❑ Owner ❑ Realtor Cl Tenant ❑ Other ------------------------------------------------------------------------------------------- FOR LAB USE ONLY - i Total 61iform / 100 ml pH Conductivity (micromhos / cm) Iron (ppm) Nitrate- Nitrogen (ppm) Sodium (ppm) Copper (ppm) // 3, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 300 Smoke Valley Road 0sterville ,Mass . Owner: Coolidge Date of Inspection:6 97 D] SYSTEM FAILS: You must indicate ei;•,er "Yes" or "No" as to each of the following: A)0 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No / Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool, I� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. �„ssgcf'1Ft�tz� )v�'Xo70' �l9 �&ff/ Liquid depth in cesspeel is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No & the system is within 400 feet of a surface drinking water supply iZ.C7- the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 300 Smoke Valley Road Osterville ,Mass . Owner: Coolidge Date of Inspectionb/1 1 /97 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Z-W As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, 4luding the Soil Absorption System, have been located on the site. Z _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Pag• 4 of 10 �l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:300 Smoke Valley Road Osterville ,Mass . Owner: Coolidge Date of Inspection: 6/1 1 /9 7 FLOW CONDITIONS RESIDENTIAL: - Design flow:gA//D p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_ Laundry connected to syst m (yes or no):� Seasonal use (yes or no): � Water meter readings, if available (last two (2) year usage (gpd): u,�. Z LlWl9�a' Sump Pump (yes or no):-Ay—) Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: 111 Design flow: A.1,4 gallons/day Grease trap present: (yes or no)" Industrial Waste Holding Tank present: (yes or no)-/9 Non-sanitary waste discharged to the Title 5 system: (yes or no)-4j) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING ECORD anq sour of information: r .l��i System pumped as part of ins a ion: (yes or no) If yes, volume pumped: allons Reason for pumping: TYPE OF STEM Septic tank/ soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 01/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Smoke Valley Road Osterville ,Mass '. Owner: Coolidge Date of Inspection:6 97 BUILDING SEWER: (Locate on site plan) Depth below grade:xr Material of construction: cas iron 4 PVC other (Main) "u 7 y�sTc Tv lkw)W dirk/te�rirr�r Distance front private water supply well or suction line Diameter �1//'/ CQjwments: (condition of joint , venting, evidence of leakage, etc.) S� SEPTIC TANK: (locate on site plan) Depth below grade: 4� Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance(Yes/No) Dimensions: l r�.y1/�'. ��7��!T 412" e Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: G Scum thicknes5:0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to b tt r of outlet teg or baffle: ✓� How dimensions were determined: l �,�{� ;4 A�0 5. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Pump Tank every 2-3 years : Tnl Pt, V nutl pt. tAAc@rp ; n nlaOP :Tank is strttnt,ttrally er)iinr - The tank ghaias nQ Sianc of Leaka P . GREASE TRAP:ZL�yl-e_ (locate on site plan) Depth below grade:—A-1? Material of construct ion:.(�i oncrete _metal _Fiberglass _Polyethylene _other(explain) - Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of�scum to bottom of outlet tee or baffle:_ Date of last pumping: v Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ('rpagp t.rap i c not prpeen+ (roviaad 04/25/97) Pago 6 of 10 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:3O0 Smoke Valley Road Csterville ,Mass . Owner: Coolidge Date of Inspection: 6/1 1 /97 TIGHT OR HOLDING TANK: /ef4,t(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:4,14 Material of construction 4q,4concreteA,�Jmetal V,4Fiberglass�UMPolyethylene42Aother(explain) Dimensions: A)A Capacity: AM gallons Design flow:_gallons/day Alarm level:Alarm in working order _ Yes; _ No Date of previous pumping: AJA Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanks are not present DISTRIBUTION BOX: &4N (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Distribution box is not present. PUMP CHAMBER:,W%,t (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) ump chamber is not present (revie.d 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Smoke Valley Road Osterville ,Mass . Owner: Coolidge Date of Inspection: 6/1 1 /97 SOIL ABSORPTION SYSTEM (SAS): Y (locate on site ,Ian if possible; excavation not required, but may be approximated by non-intrusive methods) P If not determined to be present, explain: Type: III leaching pits, number: 0 leaching chambers, number._ leaching galleries, number: leaching trenches, number,length:�_ leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (n a condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Inn sand:No signs of hydraulic failure :No signs Ali vegetation is normal Leachfield is dry - CESSPOOLS: �2 'v (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: �JA Depth of solids layer: d2d Depth of scum layer: 429 Dimensions of cesspool: &Z� Materials of construction: Indication of groundwater: AI inflow (cesspool must be pumped as part of inspection) ('P��nnnls qrp not T)racan+ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: zjd/e— (locate on site plan) Materials of construction: A44 Dimensions: Depth of solids: A,4 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present (revised 04/25/97) Page 8 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 300 Smoke Valley Road Osterville ,Mass . Owner: Coolidge Date of Inspection: 6/1 1 /97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �r04az bar.. N o o s e 't r( a� 30v SA4pke VI e ro.9 y 1 � (revised 04/25/97) Page 9 of 10 ,• I v SUBSURFACE SEWAGE DISP( .1. SYSTEM INSPECTION FORM 1 I: 1, C SYSTEM INFOR::',. LION (continued) Property Address: 300 Smoke Valley Road Osterville ,Mass . Owner: Coolidge Date of Inspection: 6/1 1 /9'7 Depth to Groundwater _ Feet Please indicate all the methods used to determine High Groundwat, -vation: Obtained from Design Plans on record (Observation o Site (Abutting prope , observation hole bast :�t sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records heck local excavators, installers Use USGS Data Describe in your own words how you established the High Groun( , Elevation. Must be completed) Augered hole to see where the water table was . Test hole was 81 . This put us 5 ' + was no water encountered below the leachfield. (zovim•d 04111197) Pag_: of 10 w V THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June a. 1995 Acting Director of the - ion of Water Pollution Control Town of Barnstable ►�� y��� Department of Health,Safety,and Environmental Services oF,►+E, Public Health'Division Date a-01 O„ 367 Main Street,I lyannis MA 02601 Ex HARNSTAHM - �'Prent�n�a+"� Date Scheduled " AG�Ust /O , i99y "Time . /•OD 19M fee I'd. -4 /00.0 O Soil Suitubility'Assess»zeizt for Sewage Disposal Performed By: ya4i Engtnee.r;pq c WilncsscdBy: 112-A.I"V LOCATION r3c;GENERAL`INFORMATION ?OOm-oke- Location Address S . v4-1Ie, �o4,y 01wrier's Name John t 19rdm/i 00-Ads J o7 Ito moss hh%/ /?.( Gsf erv)//e (LOT 8�r ,( li ress aaslon, m�9 oozi3p 111 Assessor's Map/Parcel: MQ p 97 P rC G/ f Engineer's Nante 00etLr 5 U 1 t l•earl p£ NEW CONSTRUCTION X REPAIR 'I'elephone H 50.f y 2?-3 3 it Land Use -&Nea Slopes(%) O-3% Surface Stones K0 Dislances from: Open Watcr Body''``400' R Possible Wct Arca .5 36 n Drinking Water Well 90 n I6 Drainage Way "a II Properly Line 2C It Olhcr AllO It SKETCH:(Street name,dimensions of lot,exact locations of test holes R perc tests,locate wetlands in proximity to holes) r . / MHWIq o 5 �648 - Ho °c LOT SF Uplond am _. 88,110 We 1tland r .. . '�A1S - 10t5F TOTAL 89.270t5� 4aP• Tv \ 2 o �r u� '"•150> \ �� 30 60 11•• t` r ^j' M•!,, i t 'rE✓.� \ „e.eR< j. - �I'ir^ .� If ( k• t •±.',�...� t t`1 'II Parent material(geologic) OUT WAS H PEA w Depth to Bedrock' Depth to Groundwater: Standing Water in[-tole: 78„ Weeping from Pit face 76 Estimated Seasonal Iligh Groundwater „ &RE to F_LC1AJ� s D TERMINA`TION P. It SEASONAL;H GI W. TEA TAB15 M.ethodUsed: US6SfCPC COO �Gv�.+ti.biitA--k Depth Observed standing in obs:hole: 79)11 a et-ST' in. Depth to soil mottles: ?O11 in. Depth to weeping from side of obs.hole: ?f5" im G oumiwaler Adjustment 3p" It. Index Well IN __. -, Rending Dale:IBIJ.(ZS Index Well level 9.5_ Adj.factor 2.5' •Adj.Groundwater Lcvcl q8j 1 _ _....._. _. ._ . ..._ PERCOLATION. EST uilte 10 t��ri 1.1;2?��^^ Observation Hole 9 Time at 9" " Depth of Pere A6, lime at 6" Start Pre-soak Time @ 1� .Z- , 00 25 GAa.�or.�.S ntic(9"-6" O M tV l9 End Pre-soak S l • �7 ! lr�ss t1kn.F-� 2M1�PEe.t+�►� ..._ .� ' Rate Min./inch Site Suitability Assessment: Site Passed YEs Site Failed: NO Additional Tcsting Ncededi(YM) Original: Public Ilealth Division Observation Hole Data To Be.Completed on Back j .Copy: Applicant r - bEEP.013SERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Tcxlure Soil Color Soil Other Surface(in.) (USDA) (Munscll)- Mottling (Structure,Stones,Iloulderes., onsi leu ° ravel b... ILz/Zr. Q.,. r.e ^1.o avv�Y 1p�I t2 S/ ,S Cows IS- to C. �'°r'"�n to�(241q 1M,No2 0�` s► c� GOc� O W A 76`' baG X a i-+&oT I DEEP-OBSERVATION HOLE LOG I-Iole # 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munscll) Mottling (Structure,Stones,noulderes. Consistency.°o ravel 3•,OM p ����� SY2z(Z Cows e$ ►ode-5-1 1- IZ Z C 5'A'kAv 10`l2 i I llEEI'_OI35ERVATION I1C)LE l;(?G __ Depth from Soil Ilorizon Soil•Texture Soil Color Soil Other Surface(in.) (USDA) (Munscll) Mottling (Structure,Stones,Iloulderes. Consistency."o r vet l DEEP OBSERVATION HOLE LOG Hide# Depth from Soil I lorizon Soil Texture Soil Color. Soil Other Surface,(in.) .(USDA);. (Munsell) Molding (Structure,Stones,Iloulderes. Consistency % 'ravel F l� I Flood Insurance Rate Map: Above 500 year flood boundary ,No_ Yes 1( Within 500 year boundary No_ Yes x. 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 observed throughout the area proposed for the soil absorption system? YE5 If not,what is the depth•of naturally occurring'perVious tnatenal?-'.-- 'C-" _ 3 Certification .,` I certify that on t?214 5S (date)I have passed the soil:evaluator examination approved by the Departfnent of Environmental Protection and that the. above analysis vas performed by me consistent with the required training,expertise and experience described in'310 CMR 15.017. Signature � ,o�'�Q, Lo Dale to