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Home My WebLink About0047 SAMANTHA DRIVE - Health 47 Samantha Drivc Barnstable -,— — -- — _ A= 348 — 006 — 002 Commonwealth of Massachusetts City/Town of Barnstable Percolation Test I°�* t i 3 yb Form 12 Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: A. Site Information When filling outforms on t e/ - comp ter,huse Code Realty, LLC, 52 Ship's Eagle Lane Osterville MA 02655 �� 0 (P 002 only the tab key Owner Name Lot � /to move your Samantha Drive `- cursor-do not Street Address or Lot# use the return key, (Cummaguid) Barnstable MA 02637 City/Town State Zip Code John Hutchins Contact Person(if different from Owner) Telephone Number B. Test Results I a /v:ov4. 711i�lq =�zj ( Date Time D to Time Observation Hole# Depth of Perc Start Pre-Soak �12t r l�l'h r JV End Pre-Soak �j Time at 12" Time at 9" 'aj Time at 6" Time (9„-6„) Rate (Min./Inch) WC4 Test Passed: ® Test Passed: Test Failed: ❑ Test Failed: ❑ David D. Flaherty Jr., R.S. ' Test Performed By: k Don Desmarais, R.S. Witnessed By: :a- r'Q' Comments: u :' t5form12.doc•06/03 Perc Test•Page 1 of 1 Commonwealth of Massachusetts Gtyffown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal y< DEP has provided this form for use by on-site professionals and local Boards of Health. Other forms may be used; but the information must �— be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information 1. Facility Information CI Owner Name Map/Lot / Street Addres v/ Ou 3� City/Town (oguJ LL' State Zip Code B. Site Information 1. (Check one) New Construction Upgrade ❑ Repair ❑ 2. Published Soil Survey available? Yes No ❑ If yes: (ffl3 I Y ar Published P blication cafe Soil Map Unit RV S I Name Soil limitations 16- 3. Surficial Geological Report available? Yes No ❑ If yes: vv v S Ye Published Publication Scale Map Unit r� Geologic Material Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes No ❑ Within the 100 year flood boundary? Yes ❑ No K Within the 500 year flood boundary? Yes ❑ No Within a Velocity Zone? Yes ❑ No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map - Map Unit Name DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 1 of 7 Commonwealth of Massachusetts Qtyffown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal �` 6. Current Water Resource Conditions (USGS) v ) Range: Above Normal Normal ❑ Below Normal ❑ MonthNear 7. Other references reviewed: C. On-Site Review (minimum of two holes r quired at every proposed primary and reserved'disposal area) Aly Deep Observation Hole Number: r 6 �� JUAI Date( Time Weather 1. Location Ground Elevation at Surface of Hole— F��-= Ajev iy/ Location (Identify on Plan ) 2. Land Use: - (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Vegetation Landform / Position on landscape(attach sheet) 3. Distances from: Open Water Body>/00 Drainage Way�G Possible Wet Area e>(O-V 10 feeq / ff et` Property Line fget¢ Drinking Water Well !1 5T) Other >J10D `S feet feet 4. Parent Material: 6" ti—I Unsuitable Materials Present: Yes ❑ No 2q If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No 0 If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: r DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal-Page 2 of 7 Commonwealth of Massachusetts Efown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal a` inches elevation Deep Observation Hole Number: Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure Soil Horizon/ Color-Moist (mottles) Texture % by Volume Consistence Other Depth Layer (Munsell) (USDA) (Moist) (in.) Depth Color Percent Gravel Cobbles &Stones 0' - � NJ( 4W 3 � 3 � C', Z' 5 S Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal- Page 3 of 7 1 Commonwealth of Massachusetts G4yffown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Cont.) Deep Observation Hole Number: ( U� Date r Time Weather 1. Location 11 ` Ground Elevation at Surface of Hole / O - • Location (Identify on Plan) 2 Land Use: C1L� Lv U (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(% p �—lr � Landform Position on landscape(attach sheet) Vegetation 3. Distances from: Open Water Body�� . Drainage Way LL—�' Possible Wet Are 1� fepf f t et Property Line Drinking Water Well'>�S� Other eet feet Unsuitable Material - • . • 4. Parent Material`. - s Present:- Yes ❑ No 3k— . If Yes: Disturbed Soil❑ Fill Material❑ Impervious`Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit Depth handing Water in Hole Estimated Depth to High Groundwater: 0 t— - inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 4 of 7 Commonwealth of Massachusetts r City/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Deep Observation Hole Number: Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Soil ` Horizon/ Color-Moist (mottles) Texture %by volume Structure :Consistence Other Depth Layer (Munsell) (USDA) _ Cobbles (Moist) y(In.) Depth Color Percent Gravel &Stones V� V OeL —L - . g- 36 G(� l G Z.S s p�tS Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal- Page 5 of 7 Commonwealth of Massachusetts Blown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal O 6. Current Water Resource Conditions (USGS) V yAit 2aar4 Range: Above Normal Normal' ❑ Below Normal ❑ 'MonthNear I 7. Other references reviewed: S L� v �� C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: Da Time Weather 1. Location Ground Elevation at Surface of Hole Location (Identify on Plan ) 2. Land Use: (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(/o) iNE. ra egetati n Landform / Position on landscape(attach sheet) 3. Distances from: Open Water Body Drainage Way ?�Qa Possible Wet Area fe Property Line 3S4f�et Drinking Water Well e> Other � � S�' •w �'v' feet feet Q�/ 4. Parent Material: C1&:r_AJro Unsuitable Materials Present: Yes ❑ No K If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock[-] 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from PitDepth Standing Water in Hole Estimated Depth to High Groundwater: 90"'p- DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 2 of 7 Commonwealth of Massachusetts City/Town of Barnstable ` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal inches elevation Deep Observation Hole Number: i Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure Soil Horizon/ Color-Moist (mottles) Texture %by Volume Consistence Other Depth Layer (Munsell) (USDA) (Moist) (In.) Depth Color Percent Gravel Cobbles &Stones 3If" /L s � 0- 13C Additional Notes 6�N DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 3 of 7 Commonwealth of Massachusetts G#y/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Cont.) Deep Observation Hole Number: Date Time Weather 1. Location Ground Elevation at Surface of Hole' l/ Location (identify on Plan ) 2. Land Use: 3S — (e.g.woodland,agricultural field,vacant lot,etc. Surface Stones Slope( o) Vegetation Landform Position oh landscape(attach sheet) µ 3. Distances from: Open Water Body Drainage Way Possible Wet Area, feet , � fee1t . �i J�7'�/�•w► Property Line 3z ¢ Drinking Water well � Other 6 I E ��^'� � feet feet QY 6 4. Parent Material: � �� Unsuitable Materials Present: Yes,❑ Nog- If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: C i inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal- Page 4 of 7 Commonwealth of Mass achusetts 4 q 6+tyffown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Deep Observation Hole Number. Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Soil Horizon/ Color-Moist (mottles) Texture %by Volume Structure Consistence Other Depth Layer (Munsell) USDA (Moist) (In.) Depth Color Percent Gravel Cobbles &Stones G _3 �- z8 1Olt Additional Notes /v EILU r— DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 5 of 7 Commonwealth of Massachusetts y Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal d( D. Determination of High Groundwater Elevation 1. Method used: ❑ Depth observed standing water in observation hole A. B inches inches ❑ Depth weeping from side of observation hole A. B. inches inches A ❑ Depth to soil redoximorphic features (mottles) A. . B. inches inches ❑ Groundwater adjustment(USGS methodology) A.inches B.inches 2. Index Well Number Reading Date Index Well Level _ Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of natural) occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes)a No❑ /2 jLower ` J b. If yes, at what depth was it observed? Upper boundary: boundary: inches F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.0,17 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the result my soil ev a' indicat in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. Q' Sig re of Soil Eva u or Date Lt Z Typ d or Printed Name of Soil Evaluator "Date of S it Ev, ator Exam Name of Board of Health tn Witness Board Board of Healt Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal" Page 6 of 7 Commonwealth of Massachusetts _ QWTown,of Barnstable Form I I - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method used: ❑ Depth observed standing water in observation hole A. inches B inches ❑ Depth weeping from side of observation hole A. B. inches inches �,//{I' ❑ Depth to soil redoximorphic features (mottles) A. B. inches inches ❑ Groundwater adjustment(USGS methodology) A. B inches inches ~ 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. 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 'No 13 b. If yes, at what depth was it observed? Upper boundary: Lower boundary: 2— inches inches , F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that en erf rm d b me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further. ' the above analysis has p Y so' ev ti s dicated in the attached Soil Evaluatio Form accurate and in accordance with 310 CMR 15.100 ' that the results certify Y through 15.107. /are Sign of Soil Eva �r. yal Dat Ty ed or Printed Name of Soil Evaluator *DaO of S it Evaluator Exam Name of Board of Health Witness Bard of Health Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 6 of 7 Commonwealth of Massachusetts GAy/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Use this sheet for field diagrams: DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 7 of 7 N 21 \ `\ 2\75 -,1 % 1�c// / 220.42 ot 000 �►! `° AreaA5 ,721� Vq Ft= e \ Or/ I& A�;e�a/4`�;014± S -, FtTM-3 1 \ \ 'Acres // Or 1.13 Acr �j TM-a ° HB SHAPE=19.7 �/LP / 1 FUTURE GRADING AND DRIVEWAY BY / VD t HOMEOWNERS— NOT IN CONTRACT / 4, _TM"3 \ _a \` / / °' SCHEM9 SHOWN FOR REFERENCE C 41 N29°260 E �15T— \ 1 — / �— 00 Z \ fir° 'C \ FOR SLHAPE ,as —o //\ ` l�paTH— � / TM/ \/ -, /� / Lot / � / \ lea=54,39�± q. Ft. CN C. \ Al SHAPE=17.24 TH i _ Town of !rustabX Department or..Regulatory Services Public Health Division. Date ` xr,�as annis MA 02G01 , 200 Main Strcct Ilya" A , " 0 40,4)_ Fee IN ' Tiinc Date Scheduled i 11ifor Selvage Dispossa�l »ieSoil Suit-ability lity Assess �LS Witnessed By: Performed By: LOCATION & GLNLRAL INFORMATION Owner's Name Looalion Address - Address a L ;y`• t `I. Rngineer's Name Assessors M3P/P4rcel: I . REPAIR " ` Telephone� NEW CONMUOlON , ;D d surface Slopes J Slopes(TO) t Land Use „"' " _' " �" , /0 i � Z � R Drinking Water Well Distances from: Open Water Body ( ft ' Possible WO Are. f �? � R other Drainage Way- ft Property Line i II: $lrect name,dimensions of lot,exact locations of test holes&Perc tests,locate wetlands in proxitnity to holes) SI'i'.It TC ( , /`lam. I �ti •1 ,Y, ... ;,,�-. 'C�'V' 4 Depth to Bedrock Parent material(gedldgic) I Weeping from Pit Pace ` 6I a Depth tc.Groundwaldr: Standing Water in 1101e: cf. Estimated Seasonal High Groundwater LL-- t N TION TO SEASOW�tIIGII WATER TAnLI+ I' rn DtTERMI AI I tn. Method Used: in, Dept11 to 3011 mOttlRs:_ fr. eerved standing in obs.hole: _ - ---�-- -in ord�tndwater Atjuetmcnt Depth db, dtoundweter Leval . Depth lulweeping from side of obs.hole: -�^;--^" A,O,faelbr. -- AdJ' Reading pate: index Well level•. _. s Index Well 8 (ft Ime PERCOLA'i'IUN TEST . v�t�` _ • � ~ ' Time at 4 .�-� Observation 3� I ; t, H01e 9 — t( 'Mrne al� -----�---•— Depth of Pere zme(9„4„) Start Pre-soak'lime.(a? .r 'r �a' End l'rc-soak :4 i Rate Min./inch Site Called _ �_ --- Additional Testing Needed(YIN)!--- Site suitability Assccsmcnt: Site Passed — BeCom lelcd on Observation IIole Data To P Original: Public Health Division ; *** u s o be conducted witlllin ].00' of wetland,you must first notifythe ***If percoisib test i t weelk prior to beginning. Barnstable C40servation Division at least one (1) 'DEEP OBSERVATION IIOLIr,LOG hole It Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(In.) (USDA) (Munseip Mottling (Structure,Stones,Boulders. r sl tenc rav I ------------ 33 r PEEP OBSERVATION HOLE LOG. Hole It_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsiB a is a e s • ;DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi 1 c Orav 0 , d ,DEEP OBSERVATION Ill LE LOG Hole# Depth from Soil Horizon Soil Texture , 'Soil Color Soil pthcr Surface(irr.) (USDA) (Munseli) Mottling (Structure.Stones,Boulders. ons' en �--- h1 0 13 Flood Insurance Rate Maps Above 500 ycar flood boundary No Yes Within 900 year boundary No �C Yes Within 100 year flood boundary-No Yes -- Depth of Natu nil nccurrin;Pervlous Material Does at least fo r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed f r the soil absorption system? If not,what is the depth of naturally occurring per us material? Certification I certify that on. Z VZ- (date)I have passed the soil evaluator examination approved by the Department off nvir ntn ntal Protection and that the above analysis was performed by Ine consistent with . the required training xpernse an experience described in 31U CMIt 15.017, Date • Signature Q;%SernCWJ2RC0,0R M.DOC