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Home My WebLink About0049 SAMANTHA DRIVE - Health 49 Samantha Drive Barnstable A= 00, .7 oo a . r Commonwealth of Massachusetts City/Town of Barnstable NEW Percolation Test 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 out � 1 forms the computer, use Code Realty, LLC, 52 Ship's Eagle Lane Osterville, MA 02655 r5`"V�6 60l - co` only the tab key Owner Name / to move your Y.� 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 OV Dat Time Dat Time Observation Hole# /3 y Depth of Perc 75 Start Pre-Soak End Pre-Soak ! �N Time at 12" Time at 9" Time at 6" '�V Time (9»-6°) Aj �(J�lM ✓�/ L At r�� J < Rate (Min./Inch) r Test Passed: ® Test�Passed: Test Failed: ❑ Test�Failed: — 0 David D. Flaherty Jr., R.S. Test Performed By: ! _ Don Desmarais-R.S. Witnessed By: { " ' !` r=- Comments: _ ? t5form12.doc•06/03 Perc Test•Page 1 of 1 Ind'" t1t3 Commonwealth of Massachusetts City/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal 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 j 1. Facility Information Owner Name 4m/��L! 1 IV& Map/Lot [�( Street Address State Zip Code City/Town B. Site Information 1. (Check one) New Construction Upgrade ❑ Repair ❑ l Z s � R✓ c 2. Published Soil Survey available? Yes No El If If yes: Year Published Publication Scale Soil Map Unit ' I-L - S I Name Soil limitations 3. Surficial Geological Report available? Yes No ❑ If yes. Year Published Publication Scale Map Unit SitNnz✓1��1' ox ^�E Geologic Material Landform 4. Flood Rate Insurance Map: Above the 500 year flood boundary? Yes No ❑ Within the 100 year flood boundary? Yes ❑ No X ❑ Within the 500 year flood boundary? Yes ❑ No,�- Within a Velocity Zone? Yes Nox 5. Wetland Area: National Wetland Inventory Map Ma Unit Name p Wetlands Conservancy Program Map Name Map Unit DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 1 of 7 Commonwealth of Massachusetts G+tyFfown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal V JUNL ZW6 Range: Above Normal Normal ❑ Below Normal ❑ 6. Current Water Resource Conditions (USGS) 9 MonthNear 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) 2 d Lo :0,9 ► '74, C&W4 Deep Observation Hole Number: Date Time Bather 1. Location Ground Elevation at Surface of Hole low I- /i(T-V Location (Identify on Plan ) 2. Land Use. Surface Stones Slope(%) (e.g.woodland,agricultural field,vacant lot,etc.) (t Position on landscape(attach sheet) Vegetation Landform �� g y/� Possible Wet Area /"/O 3. Distances from: Open Water Body ff—�= Drainage Wa f t feet ¢t Drinking Water Wel7f Other Z� � A�pS f /�V_ 'e/ Property Line�= feet C l9� feet 4. Parent Material: V Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock[] 5. Groundwater Observed: Yes ❑ No 9 If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: f DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 2 of 7 Commonwealth of Massachusetts G Town of Barnstable . Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal inches elevation Deep Observation Hole Number: Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure, Soil Horizon/ Color-Moist (mottles) Texture % by Volume i Consistence Y Other Depth Layer (Munsell) (USDA) (Moist) (In.) Depth Color Percent Gravel Cobbles &Stones V red), 6-1 C, 2 Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 3 of 7 Commonwealth of Massachusetts Gfty/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Cont.) 2 /� Deep Observation Hole Number: Datef Time Weather 1. Location Ground Elevation at Surface of Hole V /v�V Location (Identify on Plan ) 2. Land Use: (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) 64*, V Vegetaln p`T Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body/ li"" Drainage Way Possible Wet Area,�OV feet . fee[ / >7� feet yy fjTl S 7��e��.� /" 1�-e.✓ Property Line `-ill= Drinking Water Well > Other eet feet CF 4. Parent Material: Unsuitable Materials Present: Yes ❑ No x - 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: YO inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 4 of 7 - 3 Commonwealth of Massachusetts Gity/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 %by Volume Structure Consistence Other Horizon/ Color-Moist (mottles) Texture Depth Layer (Munsell) (USDA) ! (Moist) (in.) Depth Color- Percent Gravel Cobbles &Stones FO 3 �0 s 5.&X S . Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 5 of 7 Commonwealth of Massachusetts 3 Gityffown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal (USG TOA.;_ 26% Range: Above Normal Normal El Below Normal ❑ 6. Current Water Resource Conditions (U ) MonthlYear references reviewed: JhV1A"AIS•7. Other , C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) w e Observation Mole Number: 3 P � —� ' r- C� Deep A 4 Date Time Weather 1. Location Ground Elevation at Surface of Hole Location (Identify on Plan ) —�3 o 2. Land Use: S Y Slo ( o) (e.g.woodland, agricultural field,vacant lot,etc.) urface Stones vege tali n Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body>lO� Drainage Way Possible Wet Area> Property Line Ill Drinking Water Weil le e�� Other ItA>-1 Feet- feet t Qv CT- 4. Parent Material: Unsuitable Materials Present: Yes ❑ No 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: DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal Page 2 of 7 Commonwealth of Massachusetts C+tylTown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal inches elevation • w 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 d- 3 sqrj7 p Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 3 of 7 Commonwealth of Massachusetts � 3 Gityffown of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal r C. On-Site Review (Cont.) L 7i106 v e'UZ� - G" Dee Observation Hole Number: y p Dat Time ` Weather / 1. Location / at Surface o f Hole t /jG"V0 Gr ound nd Elevation Location (Identify on Plan ) � f 2. Land Use: W (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones 1 Slope(%) i Vegeta io �t� Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body el"? Drainage Way_ Possible Wet Area feet g fe��.� fee Q„'V � j Property Line f Drinkin Water Well Other p"�Djv� �' ` � -- feet feet 6y—S 4. Parent Material: Unsuitable Materials Present: Yes!❑ No[ i If Yes: Disturbed Soil❑ Fill Material[] Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No P If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 4 of 7 Commonwealth of Massach usetts fFfown of Barnstable On-Site Sewage Disposal 11 - Soil Suitability O g Ip Form Y Assessment for Deep Observation Hole Number: , t . Soii 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 � - 3 r 3 2 , G C � .s� Additional Notes Sewage Disposal•Pa e 5 of 7 DEP Form 11 Soil Suitability Assessment for On-Site g p g Commonwealth of Massachusetts �d7> G#y Flown of Barnstable IWO Form 11 - 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 ❑ Depth to soil redoximorphic features (mottles) A. B. (� inches inches Y ❑ 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 V_ No❑ 2 Z ^ Upper boundary: b. If yes, at what depth was it observed? J ✓ Lower boundary: S 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 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 alu n, s indica d in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. �111, �il d(9 Si nature of Soil E luato Date T v v Typed or Pnnted Name of Soil Evaluator *Date of S itIt;T va ator Exam Name of Board of Health Witness Bog d 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 G#y/Town of Barnstable Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal . r Use this sheet for field diagrams: set� DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal -Page 7 of 7 �` / � \\ �' �• � Al. � � s of 5 N / \ Or/ ' Area=4014± c 1.21-'Acres L 0 � Or 1 .13 Acre MHB / SHP =1 —z / \ i � � � SHAPE=19.7 EP/LP / 1 n FUTURE GRADIN FND \ ` l TM-3 \ �3r / e HOMEOWNERS- �\ 1 \ ( \ / SCHEM��V SH( / N29°26 0 E ,Vs► \ \ \ t FOR SHAPE 145 / :. � ,�- �, � Lot goo �' '�t/ j m / \ ,qua Area=54 ± q. Ft. �� ` m . SHAPE=17.24 '�\ .� ,� Lo 06 S 28 38�9»-44� SPLIT FND I ~ i i Town of Barnstable P# � � Department-of Regulatory Services A&—Ib Public Health Division Dare �s$ 200 Main Street,Hyannis MA 02601 Fee Pd. I. . Date Scheduled :Time — 4. $oil Suitability Assessment for So-wage Di Performed By: Witnessed By: i LOCATION&GENERAL INFORMATION Location Address'. �� . �.��• Owner's Name Address . Assessor's Map/P4tcel: f Engineer's Name l NEW CONSTRU�.n ON REPAIR Telephone* Land Use Slopes(%) ' ,Surface Stones' i �ft Drinking Wa. ter Well Distances from: Open Water Body /� ft Possible Wet Area g �l f +• ,, ' <' •.Drainage Way v v ft Propertyum, SSG— ft Other R i SKETCH:(Street name,dimensions of lot.exact locations of test holes&pert tests,locate wetlands in proxitnity to holes) -C g. i cy G Parent material(geologic) I- Depth to Bedrock ti �- Depth to Groundwaidr. Standing Water in Hole:' # . I Weeping from Pit FAt:e s'7 Estimated Seasonal;"igh Groundwater i. DtTERNIIN TION FOR SEASONAL HIGH WATEI R TABLE Method Used: I Depth 04ervcd standing in obs.hole: In. Depth t0 soil mottlt'se in. Depth toiweeping from side of obs.hole: 'i in, 0mundwatt r Ad)uattnent taetor...,._.�- Ate.fltrrundwnter Levt'1......, htdex Well#— Reading Date index Well level — = Adj. ; i PERCOI CATION TESTDate lme� Observation `Z . Timd at W, Hole# _ uL C,I i l t i I� t✓r/'L Depth of Perc GJ��" ,j} 1 Tune at b" ......�.._. 10h Start Pre-soak Time.0 'Circe(9"-b") � ..---- . End Pre-soak Rate MinAnch Site Suitability Asse¢sment: Site Passed_ Site Failed; Additional Testing Needed(YIN) Original.•.Public He*ith Division' Observation Hole Data To Be Completed on Back F _ ***If percolalibn.testis to be conducted within 100'of wetland,,you must first notify the Barnstable C4#servation Division at least one(1)week prior to beginning. r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon . Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel C 07� S g - LS 5 J7, � • DEEP,OBSERVATION HOLE LOG Hole#�.._ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gel fJ-' !� If 9'5 lqq G d . .S DEEP OBSERVATION HOLE LOG Hole 3 _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsiste vel C� 3 3 — F L .S r �° o D C ;N C DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Flood Insurance Rate Map: 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 pervi s material? _. Certi_fcation I certify that on 1l 0 (date)I have passed the soil evaluator examination approved by the Department of Envi onmental Protection and that the above analysis was performed by me consistent with the required trainin xpertise and r'ence oescribed in 3.10 CW 15.017. Signature Datei Q-%Ei-n0PERCF0RM.D0C