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LOCATION -CjS3 SEWAGE PERMIT NO.
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VILLAGE
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INSTALLER'S NAME&ADDRESS
BUILDER OR OWNEIR
DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUED
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Town of Barnstable P#_ 21 Z?
Department of Health,Safety,and Environmental Services
�V9 Public Health Division Date *:2—/ 7-;?e
Q 367 Main Street,Hyannis MA 02601
MAW
1639. �� Date Scheduled
tEo Ma+" 7 - 1..3 -�� Time Fee Pd. /T
Soil Suitability Assessment for Sewage Disposal
Performed By:A c_O ( Witnessed By: ,,,L
LOATIOX.&;GENERAI,; 1k'QRMA1'ION
Location Address�(�/j��T'//a'jj Owner's Name ke r
/- Address
Assessor's Ma /Parcel:
P (' ?j Engineer's Name
VC1.1n -em r /ter
NEW CONSTRUCTION REPAIR Telephone# 62_ys 0
Land Use Slopes(%)LiO/S Sorface Stones
Distances from: Open Water Body ft Possible Wet Area ZyO ft Drinking Water Well /70 ft
Drainage Way J 767 It Property Line 2-0 11 Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
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Parent material(geologic)Qs Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: A(/UN L Weeping from Pit Face A. 6 N�_
Estimated Seasonal High Groundwater E-4 -fir.d aW P. 9L= 70 �-
nT �rTrOrtO sAs� rA .HYH�vAT m� L
Method Used: N0 W 4 r" Aiyt
Depth Observed standing in obs.hole: in. Depth to soil mottle in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# -Reading Date: Index Well level... Adj.factor Adj.Groundwater Level_.
'T PERCOLATION TET pate :: . 6'�me
Observation
Hole#' Time at 9"
Depth of Perc
��_ �/ Time at6"
t
Start Pre-soak Time Q �l,�0 /� 3o Time(9"-V) tr 0 3 A4'W
End Pre-soak
Rate Min./inch
Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back—�
Copy: Applicant
DEEP OBSERVATION DOLE LOG I Hole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
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DEEP OBSERVATIOHNA Hol:#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
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DEEP OBSERVATION HOLE LM Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.%Gra,vch
DEEP OBSERVATION HOLE LiDG Hale# ;
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
ConsisteligL° Gravel)
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No_ Yes CL
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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? y _
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on T (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 d experience descri in 310 CMR 15.017.
Signatu __.. . _<__ Date 7[-Z,3