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- SOIL EVALUATOR& PERCOLATION TEST FORMS
Town of Barnstable Page 1 of 4
• BABNSTABIE 1 Department of Health, Safety, and Environmental Services
MAS&
°TEt639- 01 Public Health Division /•cs c
367 Main Street,Hyannis MA 02601
Off ice: 508-790-6265
FAX: 508-775-3344
So11 Sultah111 ty Assessment for Sewage Dls oral
ASSESSORS MAP K
PARCEL "3
NO. 00., 9 3 2 ! Date:
Performed By: w/�� Date: Z /C C
Witnessed By:
Q a owner's Name
I.ocat/Od`s�
Lot#: ��f /��'��f%~ / Address,and
Assessor's Map/Parcel: Telephone q
Z
NEW CONSTRUCTION REPAIR
Office Review
Published Soil Survey Available: No Yes �
Year Published `� ' Publication Scale Soil map unit y U /r'df� %�'
Drainage Class Soil Limitations d�J4�c2y 5=t/�e� Sct�°9�
Surficial Geological Report Available: No ✓ Yes
Year Published Publication Scale
Geologic Material(Map Unit)
Landform S,4iy0,11�/c IV
Flood Insurance Rate Map: Z�-0001 do%S C Ad6. 0) 198s'
Above 500 year flood boundary No Yes
Within 500 year boundary No V Yes
Within 100 year flood boundary No V Yes
Wetland Area: i9 W�rG�tiD
v � He OCG2U.9Toi1J�f�c��' Ts N6T i�t/
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: &&UAIJHIATL/)- fl T DPP X 3 7 ��' C-�Ea•�i�ry ��/'��'����
d �P� 2 T721°�c
DEP APPROVED FORM 12/07/95
FORM 11 - SOIL EVALUATOR I-Ol l
I ag
1�7
Location Address or Lot NO. aj�
/�G' e Review
-'?v Time: Weather C=�C'rrG i
Deep Hole Number cvj
Location (identify on site p Slope (°r6) /���' Surface Stones
Land Use
Vegetation
i Landform
Position on landscape (sketch on the back)
ces from: a e Way feet
Distances ' feet Drainage
Open Water Body /S� r property Line AJ f feet
possible Wet Area jZ feet other
Drinking Water Well 1SGr feet
DEEP OBSERVATION HOLE LOG'
Other
Soil Color Soil
Soil Horizon Soil Texture (Munselll mottling (Structure,Stones,Graviel)rs, Consistency,
Depth from (USDA)
Surface (inches)
"OO. Zd/
L� / z"�r- "#fTv 7'
r-y t -,1? L- lire y
�
�.���s��� pc y►�/tdr ; ; �c Tire
71
p
31,
rll—L Depthtoaedrock: <` u
"" Weeping from Pit Face:
parent Material(geologic) �� � Water in the Hole:
De th to Groundwater: Standing
EAtimated Seasonal High Ground Water:
UEP APPROrED F0101'12/07195
FORM 11 - SOIL. EVALUATOR FORM
Page 3 of 4
Location Address or Lot No. '���C( , D)
p`,�/ems
Determinatio�i ,for Seasonal Hirh Water Table
Method Used:
❑ Depth observed standing in observation hole ........ inches
❑ Depth weeping from side of observation hole ... inches
❑ Depth to soil mottles inches 100 NvTT�e5
❑ Ground water adjustment ................... feet
Index Well Number ................ Reading Date .................. Index well level .
Adjustment factor .... ..... . Adjusted ground water level .. . .......... ... . .
�Q�vNalUA?�� Gt// N� E�Ca u v rt' J -7 �- 3 7
r✓ E/z f3-iv0 fIPPiZa ';iYl��-TCG 90' lac ldr�v c3oTT��vt Or T sT �i Ts
/fie 77,
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 absor tion system? Yes
�5�� SDiZS LU 6�
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 93✓ (date) I have passed the soil evaluator examination
approved by the De artment 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.
Date
Signature �� "�`� ���
DEP APPROVED FORM-12/07/95
FORM 12 - PERCOLATION TEST
112 PaAA 4 of 4 D
Location Address or Lot No.
COMMONWEALTH OF MASSACHUSETTS
-;1r7W4,e- , Massachusetts
Percolation Test*
Date: Time:. :.. :..
Observation Hole
Depth of Perc T1
Start Pre-soak ��; L 3; � A/►�
End Pre-soak
Time at 12" /,4,
Time at 9"
12
Time at 6"
Time Z 9"-6") S; 2
1 �a /�
G
Rate Min./Inch
Minimum of i percolation test must be performed in both the primary area AND
reserve area.
Site Passed B Site Failed ❑
Performed By:
Witnessed By:
a1i i.�i r
Comments:
DEP APPROVED FORM•12/07/95
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LagM
/ZO + I EL. 68.3
7
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R�8 BARNSTARLE CONSERVATION
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TOWN OF BARNSTABLE
LOCATION �h� ��j�� f �� SEWAGE #
VILLAGE r'nr1 y/, ASSESSOR'S MAP &LOT/,S�Z 03-04
INSTALLER'S NAME&PHONE NO. ✓1 7—A(PV 0 0
SEPTIC TANK CAPACITY S—C)
LEACHING FACILITY: (type)C6/ii'!Cj/ (size) /C)X VO
NO.OF BEDROOMS /
BUILDER OR OWNER !f G �
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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) L 1 Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility)) Feet
Furnished by `' �1�'
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