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Town of Barnstable P#
Department of Health,Safety,and Environmental Services
�t►,E, Public Health Division Date 3�2/9?
367 Main Street,Hyannis MA 02601
BARNSTeeIA
MASa
Date Scheduled / � Time '(/G Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By: f�� ���`�� Witnessed By:
LOCATION & GENERAL;INFORMATIO
Location Address L a #fi/r/� H Owner's Name ate,'� L O�Q
Address
Assessor'sMap/Parcel: �Y� Engineer's Name
NEW CONSTRUCTION REPAIR Telephone# /.,7 y�
Land Use S/•-r f 1-7fry Slopes(%) Surface Stones Ald
Distances from: Open Water Body l�+®, ft Possible Wet Area ft Drinking Water Well /V/,/ ft
Drainage Way ft Property Line ?S ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlards in proximity to holes)
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Parent material(geologic) ` Depth to Bedrock
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Depth to Groundwater: Standing Water in Hole: /� (� Peeping from Pit Face Al
Estimated Seasonal High Groundwater
RE'I'ERMINATIUN FOR SEASONAL.HIGH WAT: R TA�T�E
X.
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Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles 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_
I PERCOLATION TEST nateil ;Trme %1
Observation
Hole# Ti � Time at 9"
Depth of Perc Time at 6"
Stci^r_-so^k i ime r x)3-� Time(9"-6")
End Pre-soak A ?10:
Rate Min./Inch 2,f 61P' WV IAJ oor`07'SS"'
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YM)
Original: Public Health Division Observation Hole Data To Be Completed on Back
T Copy: Applicant - 41
DEEP OBSERVATION HOLE LOG Hole
Depth from Soil Horizon Soil Texture Seil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.% ravel
DEEP OBSERVATION HOLE LOG Hole# T'
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel)
% S.L
DEEP OBSERVATION HOLE LOG- Hole#
Depth from Soil Horizon soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.% ravel
DEEP OBSERVATION HOLE LOG ,Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No_ Yes
Depth of Naturals 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?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (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 and experience described in 310 CMR 15.017.
Signature Date