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Department of Health,Safety,and Environmental Services
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�t►+E, Public Health Division ' Date_ _ -
,XT� $ 367 Main Street,Hyannis MA 02601
S 9ARNBTABM _ Gy
0 Date Scheduled / A _ Time jD�y, Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By: Witnessed By: ��i22� �u�✓wiN(�
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LocetionAddress C, ...AL AV l�v���wj,r� Owner's Name takly �Zp•� l�i/(r�
C/ k 'I Address q' G t kCdl�►
Assessor's Map/Parcel: �{ /Z Z Engineer's Name./9L(� GAP,2 �N6 ii✓t Eli 6r
NEW CONSTRUCTION !/ REPAIR Telephone#
Land Use Slopes(%) g'/I Surface Stones NO
Distances from: Open Water Body ft Possible Wet Area >/oU ft Drinking Water Well >ioo ft
Drainage Way It Property Line ft Other ft
�iST2iGi, 1//12/ANLu1 MAX /?43
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SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
)lot
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Parent material(geologic) 00-1 w4fa P[41-1 IrS Depth to Bedrock 3SV +
Depth to Groundwater: Standing Water In Hole: X10 Weeping from Pit Face
Estimated Seasonal High Groundwater x ZOO 736C oL-) 6eAAva
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Xx
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Method Used: G ZOO 1VOL41A7' /L. /V%j
Depth Observed standing in obs.hole: in, Depth to soil mottles: IVA in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. �.
Index Well N_ -Reading Date: Index Well level.-.—__ Adj.factor Adj.Groundwater Level_
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Observation ,
Hole H � Time at 9"
Depth of Perc a y8�'LU Time at 6" Z� " z /
Start Pre-soak Time @ O Uy O'�' Time(9"-6") O $ O Z
End Pre-soak
Rate Min./inch `'Z A"Z 63/0 /oS67S1
Site Suitability Assessment: Site Passed _ Site Failed: No Additional Testing Needed(Y/N) /y
Original: Public Health Division Observation Hole Data To Be Completed on Backer .
Copy: Applicant
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Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in. (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
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Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
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9- z wL ',140 /dye
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Depth from Soil Horizon Soil Texture Soil Color Soil Other..............................
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
%
I
EEP OBSER::':aT O> HOLELO >>> >< : < » . ><_ ` :::>»<<>'>•< <:'' ;.`'<
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Depth from Soil Horizon Soil Texture ' Soil Color Soil'<;.., t p Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
%
Flood Insurance Rate Maw,
Above 500 year flood boundary No— Yes
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? `&
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on G -/G-%5 (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.
atgre Date Sign U