HomeMy WebLinkAboutMiscellaneous - 54 STERLING LANE 3/3/2016 Town of North Andover, Massachusetts Form ®.a
AORTN BOARD OF HEALTH "*IelG / -
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19
A
`t°• --=-`r DESIGN APPROVAL FOR
S-TA CNUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant % Test No.
Site Location
Reference Plans and Specs-
ENGINEER
�. /ate/��
(ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
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in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
Fee
Site System Permit No.
FORM 11 -SOIL EVALUATOR FORM
Page 1 of 3
No- Date:
Commonwealth of Massachusetts
Massachusetts
foil Suitahility Aaemnz or 0 wage
Performed By: Date:
Witnessed By: ' C
Location Address or Owner's Name
Lot# Address and
l (,
Telephone hone#
ol >
New Construction , 7 Repair
l �
Office Review
Published Soil Survey Available: No Yes
7
Year Published Publication Scale Soil Map Unit
Drainage Class ',, Soil Limitations
Surficial Geologic Report Available: No Yes
Year Published Publication Scale
Geologic Material(Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year flood boundary No Yes
Within 100 year flood boundary No Yes
Wetland Area:
National Wetland Inventory Map(map unit)
Wetlands Conservancy Program Map(map unit)
Current Water Resource Conditions(USGS): Month
Range: Above Normal =Normal =Below Normal
Other References Reviewed:
— DEP APPROVED FOM-12/01/95 wileveLaam
FORM I I - SOIL EVALUATOR FORM
f
Page 2 of 3
Location Address or Lot No. z
Ott - Site Review
Dee Hole Number ` - Date Time
P Weather
Location(identify on site plan) >,
Land Use . Slo % ��' �
p e( ) Surface Stones ,
,.s
Vegetation -a r
Landform
Position on landscape(sketch on the back)
Distances from:
Open Water Body �- feet Drainage way f feet
-Possible Wet Area. fdet Property Line ' feet
Drinking Water Well "s feet Other
F
DEEP OBSERVATION HOLE LOG*
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency,%
Gravel)
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7/r
'MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Parent Material(geologic) ��,! Depth to Bedrock: •'.�'-
Depth to Groundwater. Standing Water in the Hole: -- Weeping from Pit Face:
Estimated Seasonal High Ground Water: a //
DEP APPROVED FORM-17107t95 wilrnl.,am
FORM I 1 -SOIL.EVALUATOR FORM
Page 3 of 3
Location Address or Lot No.- '
Determination for S'easonaLLU
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Water Trabte
Method Used:
Depth observed standing in observation hole inches
Depth weeping from side of observation hole inches
Depth-to soil mottles rx< '. inches
Ground water adjustment feet
Index Well Number Reading Date Index well level
Adjustment factor Adjusted ground water level
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? s
If not-,what is the depth of naturally occuring pervious material? '
ertifica ion
I certify that on " `
� l (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.
Signature '�9 Date
F'
DEP APPROVED FORM-12107/93 wileval�am
FORM 12 - PERCOLATION TEST
Location Address or Lot No.
COMMONWEALTH OF MASSACHUSETTS
Massachusetts
Perccflation Test*
Date: Time: ,?
9
,�r' 0
Observation Hole#
Depth of Perc ;L}
,n �'
Start Pre-soak
At
End Pre-soak
Time at 12" 'r
Time at 9" r"
F„
Time at 6"
Time (9"-61
Rate Min./Inch
*Minimum of 1 percolation test must be performed in both the primary area
AND reserve area.
Site Passed Site Failed
Performed By: '"
Witnessed By: yr ,
Comments:
DEP APPROVED FORM- 12/07/95 PmtncS/w