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Town of Barnstable P
Department of Health,•Safety,and Environmental Services
ofWE Public Health Division Date
367 Main Street,I lyannis MA 02601
BARNMBIE, • .
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rEnr�et Date Scheduled .Time i 00 Fee Pd. k00,
Soil Suitability Assessment for Sewage Disposal
Performed By:t Ui��b MA' . ltJ Witnessed By:, o10," s 4 /f�/*O
LOCATION & GENERAL INFORMATIONc-�
Location Address�Zo Owner's Name�ml rxe S
o C�R� �'
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J�C1�.Ati.�YLCM w�J V "'N;ddress
Assessor's Map/Parcel: `"'QC) rp �[��_ Engineer's Name &fa— �
NEW CONSTRUCTION ✓ REPAIR Telephone# �71'1-- L72
Land Use l`-' v d4 l o " Slopes(%) ��z <o Surface Stones �a +
Distances from: Open Mate?Body R Possible Wet Area f3 Drinking Water Well It
Drainage flay .1111 Pmpv ly L6rte R Other � It
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) Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
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DETERMINATIGiN YCIZ>SEA.SONAL HIGH WATER TABLE
Method Used:
Depth Observed cra-A;np in nbs.hrile: tn_ nPr}s;In c.at mntlt":
Depth to weeping from side of obs.hole: in. Groundwater Adjustment R.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
Observation
Hole# Z. Time at 9"
Depth of Perc s� Time at 6"
Start Pre-soak Time c@ ��' Time(9"-6")
End Pre-soak �� '4 8
Rate Min./Inch G Z
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 `
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DEEP.OBSERVATION HOCKLOW "' Hole#
Depth from Soil Ilorizon Soil Texture oil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
,/ Consistency,° Gravel)
Xft ,ey III Z'IZ r/6
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6/1
5(2"- 137-
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DEEP OBSERVATION HOLE LO.G Hole# 2—
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
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32— �G v Cr Sev-11 10YR. `lr:
,P6 13L " C1 6/y
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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)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Ilorizon Soil Texture Soil Color Soil 01her
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,% 'ravel
i
Flood Insurance Rate Man:
r/
Above 500 year flood boundary No_ Ycs
Within 500 year boundary No Yes
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? 7e x
If not,what is the depth of naturally occurring pervious material?
Certification
1 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 �� —2 7—
S Date y S 9