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Department of Health,Safely,and Environmental Services
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Public Health Division Date '
367•Main Strict,I lyannis MA 02601
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Date Scheduled Time ►oo —
Soil Suitability Assessinentfor Sewage Disposal
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Witnessed By: C$R-1
Performed By: (�AX
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LOCATION &'GENERAL INFORMATION
Owner's Name H-VZ-H C u=tt_L-
LocationAddress LcDT 2 6 -1-7 A-E-
QQ-AIL. (_, v >e 4 �OL=tN`ILL R-0
Address V.l - , MA., o�1-15_4'
I-IyA'I�NISPOa-T, MA
Engineer's Name (�AXrE$
Assessor's Map/Parcel: 28-1 tog PA-2T g
NEW CONSTRUCTION ✓ REPAIR
"telephone#
Land Use QE 5i B e,-+.n A t_ Slopes(%)
3- S Surface Stones
Distances from: Open Water Body
do R Possible Wet Area � (-` tl Drinking Water Well —1A R
Drainage Way '_A_R Property Line ___
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SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
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Its. o� 4a.M. 39•A"S�CDCD
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Parent material(geologic) Depth to Bedrock A
Depth to Groundwater: Standing Water in Hole:
ti,o 4,ovvea. Weeping from Pit Face
Estimated Seasonal High Groundwater
41=1' n®An
DETERMINATION FOR SEASONAL HIGH VVATI!,R TABLE, �a
Method Used: in.
Depth Observed standing in obs.hole: in. Depth to soil mottles:
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 "bate i2_g 9s Time
Observation ( 2 Time at 9" it '3 5
Hole#
-WP a Time at 6"
Depth of Perc A or a
Time(9"6") 2 t^IN 1
Start Pre-soak Time Q -�—
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End Pre-soak it
Rate Min./Inch
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Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back--j
Copy: Applicant
DEEP OBSERVATION HOLE LOG Mole#
Depth from Soil I lorizon Soil Texture Soil Color Soil
Other
(USDA) (Munsell) Mottling (Structure,Stones,Doulderes.
Surface(in.) °
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DEEP OBSERVATION HOLE LOG Hole# 'V
Depth from Soil Ilorizon Soil Texture Soil Color I Soil
Other
Surface from
(USDA) I (Munsell) Mottling (Structure,Stones,Doulderes.
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(+� M.S (CG
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DEEP OBSERVATTON'HOLE'LOG lIolc#
Other
Soil
Surface(in.) (USDA) ( )
Depth from Soil Horizon Soil Texture Soil Color
Mottling (Structure,Stones,Doulderes.
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DEEP OBSERVATION HOLE LOG Hole
(M.msell other
Depth from Soil Horizon Soil Texture r Soil
Mottling (Structure,Stones,Doulderes.
Surface(in.) (USDA) ) °
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Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No✓ Yes
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Within 100 year flood boundary No✓ Yes
Death oNatu raly 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? Ire
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If not,what is the depth of naturally occurring pervious material?
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�grtification
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.
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Signature (�F4YtV-0-4I-V-fa roc_ Date
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