332 Title 5 Documents 1996 No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date: b/a//y�
Commonwealth of Massachusetts
, Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By:
Witnessed By:
TM CroC !a,
t der /Pi1CCr./o c
Date:
a^1' Rear 33a Nor+F1 rvr1S pc)
New Construction K'l Repair ❑
Gary WarNer
3a1 NO-CA Fame
Office Review
Published Soil Survey Available: No ❑ Yes ❑
Year Published
Drainage Class
Publication Scale
Soil Limitations
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit) q p
Landfonn K4/1) Ti 7G f is a e
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes ❑
Within 500 year flood boundary No Dyes ❑
Within 100 year flood boundary No ❑Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Soil Map Unit
Current Water Resource Conditions(USGS): Month
Range :Above Normal co Normal ❑Below Normal ❑
Other References Reviewed:
DPP APPROVED FORM-12/07/95
en-affe view V i cce( d - l�<Pr f�IC C�[�c
Location Addr- 'r Lot# �.
Depdndorn
Surface(Inches)
:..l.eL' C r N - • ' 11_•. ■
Sol Tad=-
(USDA)
– 4 &
Deer Hole Number
—rllWeIFlILti' Time nnaaai Weather WW0
site plan r
9 —
1■,1
34, - 9s
- -\
Location(identify on
Land Use
I
I SloPe(%) I —
I
Surface Stones I A/p7710
,.g,„ L-, ec
sou .c .,
A-
" 7>
Vegetation
PaemMaMaI(geabgb) I Depth lo Bedrock I
Depth groundwater Sbndon Wad in the Hole
:75/19r' I WeepM Can PiFace I AY/3A'gg_
_
"R e)3/4-
Landform
f_ .
Position on Landscape(sketch on the back) I
-
Distances from:
Open Water Body L)I in) r
feet
Drinking Water Well
/D39 '
feet
Property Line
\,
feet
Possible Wet Area
71 aryo '
feet
Drainage Way
>M c,
feel
e[
\
feet
DEEP OBSERVATION HOLE LOG'
Deep Hole t I 'MINIMUM DP TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depdndorn
Surface(Inches)
SW Halm
Sol Tad=-
(USDA)
Sod Con,
LA+mM
SW
MdBnv
Other
/(sducse,Stones,Boulders,Consblency,%Graver)
9 —
1■,1
34, - 9s
- -\
\LI
$
0 I
C a-
CI)
5 L
1-.5
00 /1
10 1)..
sy .5/y
I®tUII/
1 9 /
fo
Sii)s
/a 30-�r
,.g,„ L-, ec
sou .c .,
A-
" 7>
taro
PaemMaMaI(geabgb) I Depth lo Bedrock I
Depth groundwater Sbndon Wad in the Hole
:75/19r' I WeepM Can PiFace I AY/3A'gg_
Palmated Sensate)HO Ground Water
"R e)3/4-
�� DEEP OBSERVATION HOLE LOG' -
Deep Hole I: *I INDIUM OF TWO HOLES REQUIREl1AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(Inches)
SW Hat=
Sad Texture
(USDA)
Sod Cobr.. .
acme/
Sad
MoIS
Other
(Structure,Stine.Banters,Ca'Hknci,.%
_Q.._I-I
\i"- Lc
�d -N
fK Iri%
AF
C(
C 3
ti -7
5 L
ter gib__
.
-.
1 .
%Gravel))
- -4-e_- ¢I'-60- 4-E
- -
r„
t ,
sys/y
1sl� 4//4
109„11 V
taro
L
, s
-cocau
- —
Parent tibal(gedopb) I ' Depth to Bedrock
Depth',groundwater Sbndoq Water in the Hon
I F Weep%tan Pt Face I %:/e9
Estimated Seasonal High Ground Water
f_ .
sfreAt
clam YID 1rC
p FORM M.PERCOL/AATIOON TEST
Lxnion Address or Lot No. /i-r-1/-s. /L�' 414- `v-
COMMONWEALTH OF MASSACHUSETTS
,Massachusetts
•Minimum of I perpeLWar!tdit Rant be performed In bath the primary area AND
MOM*fey .
sc.f+.ssen a Ste railed ❑ •
Per/amed Byt JyaA C `„ •
Witnessed By:
Comments:ants: _
S
FORM 12-PERCOLATION TEST
Location Address or Lot No. . - -
COMMONWEALTH OF MASSACHUSETTS
Massachusetts
Percolation Text
Date: _. - �p Time: ! _
Observation Hole f
Depth of Perc
Start Pre-soak
End Pre-soak
j G
Tune alz ID
Time at e• (-Y
rime at 6•
Time 1D•-61
Rate Min.Anch
•Minimum of 1 percolation test most be performed in both the primary area AND
reservee,err
Site Passed Ly Site Failed ❑ '
Perfomled 61': (c C -,t.
Witnessed BY 11-')i/-°"•"E 0- {N P c (- ' --
Comments:
IMOVZ17•0411-1247n1
v
f7
/
arkk Ailed Ky Ji wt (great iq,
0q-Site Review Wye i€r Mc& 'cB. vl
—r
Location Addres or Lot#
Depth from
Surface(Inches)
,pa 3 _ .2 i
Sod Texture
(USDA)
Sod Color
(Munson)
. Or B e 11_•• '.._
C r
Deep Hole Number gate
a ,. Time ' - Weather (.
Location(identify on site plan
40
l s
s�
got,Li
Land Use
I Slope(%) I - 1 Surface Stones I -z/y F
£
r.
k]7 tw 'At, ',/
1)'�
Landform
Landform
Depth bgroundwater. Standing Water in the Hole
Position on Landscape(sketch on the back)
Distances from
Open Water Body
i I /Id ' feet
Drinking Water Well
> /(-O feet
Property Line
feet
Possible Wet Area
>/ feet
Drainage Way
>/c-c feet
Other
feet
DEEP OBSERVATION HOLE LOG'
Deep Hole R: / *MINIMUM OF TING HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(Inches)
Soil Ha'von
Sod Texture
(USDA)
Sod Color
(Munson)
Soil
Mottling
Other
(Sbucire,Stones,Bakers,Consstency,%Gravel)
m
1.
40
l s
s�
got,Li
a/�
�
1t/
le 7r
�1 /
£
r.
k]7 tw 'At, ',/
1)'�
1 ,
_,20-o- c -e A---,- C
Parent Mabial(geobgb) I Depth to Bedrock I
Depth bgroundwater. Standing Water in the Hole
>/,/Lpir' I Weeping from Pit Face I �11/(J NL°_
Estimated Seasonal High Ground Water
in t,'
DEEP OBSERVATION HOLE LOG*
Deep Hole#: 'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(Inches)
Sot Horizon
Soil Texture
(USDA)
Soil Color
(Mbnsell)
Soil
Molting
Other
(Structure,Stones,Boulders,Consstency,%Gravel)
m
o({Mp S
„^
,off yip
(0vLi /17
IGIa
,,2.5r
5y57/
i
163mr
1
i22<m-e -<.a-L-C
AVLfi� Li(< r v, 36
c
Parent Mafial(geoogb) I I Depth to Bedrock I
Depth to groundwater Standing Water in the Hole
1 '11, I Weeping from Pit Face I A'O/%e
Estimated Seasonal High Ground Water
`3
15