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11 - SOIL EVALUATOR FORM
Page 1 of 3
J U L 1HEALTOF Date:
No. � n �,6
Commonwealth of Massachusetts
lore
ti,Aa,,sT*&L-e7 , Massachusetts
tabili A sessment or On-site Sewa a Dis osal
oil Sui
..........:............
1��
Performed By: ............... Date:
... ... ... ......
............
Witnessed y: .........,......:........... .. ...
S Sc,2s YY►RP l`t3 (fgtw
Owner's wine.
Location Address or 0Address. ) A A and //, P.Q � T- /� �Q Lot/ L lG � Tekpzo / �^.wV �_I
l.vv��� �'' C�UT��lc t� G f cam, '�I✓A-�t� # ►J Vim`
ew Construction l�.Repair ❑ /o
Office Review
Published Soil Survey Available: No ❑ Yes it
�,�,
ia`13.•. Publication Scale !.:.15 Soil Map Un
Year Publish
ed
Drainage Class ..a............ Soil Limitations
Surficial ❑ Yes Geologic Report Available: No ` 2� o o e
Year Published
` :g.::.. Publication Scale
.....................
a .........c?g'r........................................................................................................ .
Geologic Material (Map Unit)
oc� - ...................................................................
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No
[]Yes
I�
od boundary
Within 500 year flo
No 0Yes ❑
Within 100 year flood boundary No Yes ❑
Wetland Area: ! �./A................................................... ............................
National Wetland Inventory Map (map unit) ...'t..aEA.... or.�,.-0c .P..............
Wetlands Conservancy Program Map(map unit)
Current Water Resource Conditions(USGS):
Month s 4co.
Range :Above Normal BNormal ❑Belcw.Normal ❑ c J� G�� (L
Other References Reviewed: us
DEP APPROVED FORM.12/07/9S
u i
FORM 11 - SOIL EVALUATOR FORK',
Page 2of3
Location Address or Lot i�o. Lor l03 LoNc�g T DQwt' Cc-,,7=0L4II-L9�
On-site Review
II. flan Weather
-, �Q �9�. Time...I o
Deep Hole Number ...1... �-:: Date _
Location (identify on site plan)
k-r g,�...P(�oPes>=C)...PQIMA-n � lQ;� CQ�� L�n. :fr
Sloe (°/u) . -Is
Surface Stones tioNE oFsscwcD _
Land Use P�000�z`�5F p„
vncn-err- p -
��L-L1tiILrlrL r v-E� �0:.��''�
Vegetation . ,..P „ALL ;cLE+�n lP
Landform
Position on landscape (sketch on the back) - -
Distances from.:
Open Water Body
15� feet � Drainage way :�%a... feet
Possible Wet Area feet 1 Property Line 38......: feet t
Drinking Water Well feet Other . '
DEEP OBSERVATION HOLE LOG*
Other
i Soil Texture Boulders, Consistency,
Depth from Soil Horizon Soil Color Soil Gravel)
Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,
ko,
O — 1 " O 7i V L-L T- Q.A,
1° 5 E I� �i.or-�t= !•ne0 sf�„e v=G'-! FE,r�r��=
5rr 45r f3 M -D io ie 5
G I M S L.5 1�'�. 1�oM rc.
(-1Q.to WI(•Qr A-�LC
5L ene.p Sr�G .�EQ-y F&.rA-n�C--
C-
W o WA'IT�- 0
Top *8" _
Pe0-c Aar _---— - - _
-r-r-2
ni +l�-
�o ti 6 .Ti..n C-y f-o R.c• r r�''itQn l
- E L 5
1 - S n.�S I o Y 2 S I c.. tifu r-.E M co 5 tci..i/� , v EQ�r Fes.H4S i-C
e76 SA_0f'Qn/-l�l-E
G MS 2.5,{�la-
M o¢ 1 I r DepthtoBedrock:
Parent Material(geologic) Weeping from Pit Face: 1 A
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water:
DEP APPROVED FORM-12/07/9S
r .
FORM 11 - SOIL LVALUATOR FORM
Page 3 of 3
Location Address or Lot No.
Determination for Seasonal HiLM Water Table
Method Used:
❑ Depth observed standing in observation hole inches
❑ Depth weeping from side of observation hole ......... inches
❑ Depth to soil mottles .....::.:.:::::::. inches
Ground water adjustment .....!.--J....... feet
Index Well Number ..:252/a Reading Date ...:7 ate. Index well level ..�t�. .
Adjustment factor ......!.:..I...'. Adjusted ground water level .............. ..'.............................
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? YES
If not, what is the depth of naturally occurring pervious material? ti/A
Certification
I certify that on s/9 s (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, exper«se arid expel ic„ce
described in 310 CMR 15.017.
Signature -� Date 9
DEP APPROVED FORM-12/07/95
FORM 12 - PERCOLATION TEST
t
Location Address or Lot No. L nT
COMMONWEALTH OF MASSACHUSETTS
G�ut��lILL6 �STL6 , Massachusetts
Percolation Test*
Date: �, Time:. ..:
... :, .L
.. .
Observation Hole # l
i
Depth of Perc i $
Start Pre-soak
End Pre-soak o , 1
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate Min./Inch ,� M ,+,
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed Site Failed ❑
Performed By: e'-'- s ,� ''"' = "_'C
Witnessed By: 7--n L E- (1,
c.
4-4
Comments: ......
.......n.....v.......... ...... ......w. . ............... ....................... w...�w.. »...............................,...............rv.v.w.»...._..
DEP APPROVED FORM-12/07/9S
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