HomeMy WebLinkAboutMiscellaneous - 28 FULLER MEADOW ROAD 4/30/2018 (2)9
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AF
DEPARTMENT OF ENVIRONMENTAL PROTECJVC�kECEIVED
NOV 2 1 2005
TOWN OF NORTH ANDOVER
TITLE 5 1 HEALTH DEPARTMENT
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Owner's Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Date of Inspection: I I November 2005
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 60 Beechwood Drive North Andover, MA 0 1845
Telephone Number: 978-686-1768
CERTMCATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CMR 15.000). The system:
�/Passes
Conditionally Passes
—Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
The system inspection shall submit a copy of this in�ion report to the Approving Authority ( Board of Health or DEP) within 30
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and
the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system
owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does
not address how the system will perform in the fijture under the same or different conditions of use.
2 4 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR
15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
& System Conditionally Passes:
A.)0 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,
upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (YNND) in the for the following statements. If "not determined" please explain.
—The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a
complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the
tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if
(with approval of the Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
ND explain:
. 13o f I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
C. Further Evaluation is Required by the Board of Health:
No Conditions exist which require ffirther evaluation by the Board of Health in order to determine if the system is failing to protect
public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is
not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
— The system has a septic tank and (SAS) Soil Absorption System and the (SAS) and the SAS is within 100
feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well". Method used to determine distance
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organize compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
4 o� I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surfitce of the ground or surface waters due to an overload or clogged SAS or
cesspool.
t/ Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times
pumped
Any Portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is within a Zone I of a public well.
Ll Any portion of a cesspool or privy is within 50 feet of a private water supply well.
,-` Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
—No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in
3 10 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must iqd�ficate either "yee' or "no" to each of the following:
(The followinik-en�teria apply to large systems in addition to the criteria above)
Yes No
The system is , 4. fee of a ace
w6"' 0' t surf
f ut ry
The system is within 200 �eetrib a water supply
The system is located in a
of a public water supply -�
(Interim Wellhead Protection Area – IWPA) or a mapped Zone 11
If you answered "yes" to an"uegfion in Section E the system is consider ignificant threat, or answered "yes" in Section D above
the large system has 9fa
ilecL' The owner or operator of any large system consi ereA-asignificant threat under Section E or failed under
Section D sball upgfiade the system in accordance with 3 10 CMR 15.304. The system`o7 should contact the appropriate regional
office of the Department.
5 �f 14
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
Check if the following have been done. You must indicate "Yes" or "no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks-?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of an inspection ?
V Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for sign of break out?
Were all system components, excluding the SAS, located on site?
Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the
baffles or tees, material of construction , dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner ( and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
71_� Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [3 10 CMR 15.302(3)(b)]
6 of 14
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design)__=::j_ Number of bedrooms (actual)L._�
DESIGN flow based in 3 10 CMR 15.203 for example: I 10 gpd x # of bedrooms):
Number of current residents:- 3
Does residence have a garbage grinder (yes or no): MO
Is laundry on a separate sewage system (yes or no): t20 [if yes separate inspection required]
Laundry system inspected ( yes or no): — , .
Seasonal use: Cyes or no): IV 0 .
Water meter readings, if available (last 2 years usage (gpd): -ro Wj%j
Sump Pump (yes or no): A)Q
Last date of occupancy_6j
CtC,,AL
COMMERCIAL/E1qDUSTRLAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft, etc
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no)
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe
GENERAL INFORMATION
Pumping Records
Source of information:_ A --a P_-, L_ zc,09- vol, E A -
Was system pumped as part of the i1spection (yes or no): A10
If yes, volume pumped: llons - How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
InnovativetAlternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tight tank Attached a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
E XIJ A)?
Were sewage odors detected wen arriving at the site (yes or no): NO .
7of14
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
BUELDING SEWER (locate on site plan)
Depth below grade:
Materials of constrtictiow. %,/ cast iron 40 PVC other (explain)
Distance from private water supply well or suction line:— Allll�-
Comments (on condition ofjoints, venting, evidence of leakaje, etc.):
, i�lc- &V 0 J:) I A-) - f3tfs&�;L4 e
SEPTIC TANK:_(Iocate on site plan)
Depth below grade: I z
Material of construction: v,-' concrete metal fiberplass----polyethylene
Other (exp
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate)
Dimensions: 1,5- o Cfq L. 1, 0 /,1 S
Sludge depth: /- -A
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:- 1-1
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle ;2 0
How were dimensions determined: " ei �� rz e 5-1) C //-
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
-rnAJ 1.4 tAo 6-000 co ,-) P IT? 0 -1 � c c -,-,-i c r e -/-F /^-/ olk C(),.j L-),7) 0/-J,
e, 0 -&OA /ra-c 1< yt-r PA -4--,
1,V 5 P 65-C-77d,--
GREASETRAP: /t/-1 (locate on site plan)
Depth below grade:
Materials of construction: concrete metal
(explain)
Dimensions:
fiberglass —polyethylene other
Scum thickness: -
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of sludge to bottom of outlet tee or baffle:—
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.
8 of 14
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
TTGHT OR HOLDING TANK: /V L4 (Link must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials of construction: concrete metal fiberglass ____polyethylene other
(expl
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTROUTIONBOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 6)
Comments (note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
I'll 6-0 0 O/J All luo e,1,c,0eAce oF
e-Q�) A
PUMP CHAMBER: AJ 0 (locate on sire plan)
Pumps in working order (yes or
Alarms in -working order (yes or no)_.
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
9 of 1-1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Fuller Meadow Road N. Andover, MA 0 1845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
SOIL ABSORPTTON SYSTEM (SAS): (locate on site plan, excavation not required
If SAS not located explain why
FbTr-a
leaching pits number
leaching chambers, number
leaching galleries number -
leaching trenches, number in length
-.41—leaching fields, number, dimensions: I fi Q� r)
overflow cesspool, number:
innovative/altemative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc)
0 14 t,)- 9,%4R I-, I f) F,,r C,�- C)1g:::, ;-C) P t) I AJ C1 --
L Ve-&-u -r-04-D 1)
CESSPOOLS:AI)A, (cesspool must be pumped as part of inspection) (locate on site plan)
r—
Number and configuration:
Depth – top of liquid to inlet invert
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of Construction
indication of groundwater inflow (yes or
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Material of construction:
Dimensions:
Depth of solids
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
10 of 41
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Fuller Meadow Road N. Andover, MA 01845
Owner's Name: Larry Buote
Date of Inspection: I I November 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
all wells within 100 feet. Locate where Dublic water sunnlv enter% the buildino -
j7> I 5r -j Iq A) C E 5
--r 2C (
z. --r zs(
-PP
2 33-S
Locate
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Property Address:
Owner's Name:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
SYSTEM INFORMATION (continued)
28 Fuller Meadow Road N. Andover, MA 0 1845
Larry Buote
I I November 2005
Estimated depth to ground water 6 feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record — If checked, date of design plan reviewed:
;K Observed site (abutting'property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
V IZ9 (/-, CTI -f �j c) A^?
5- 4- C, 1--Ce7- Fi— L-A V r)
tz C-- + (L 0 �r ? V-0 9 C-- g�-
r0WN OF NORTH ANCK)YEP,
UA SYSTEM PUMPINQ REC()R-b
iTEM O"ER 4X AWKESS
AcQr�ql vo /— .0 ,
�PZWI-er lVe4yow b/
012dovel,�-, Ma -
SYSTEM LOCA71ON
DATE. OF PVWNQ:_ - - -
QUA NnTY PUMPED:
VWSPOOL: NO
-2� ... .... SoNc Lnk: Nu. YES
NA rVKU OF SBRVIcE: RoVrINE.."ROENCY
OUSBRYK17101413:
0000 CONDITION FULL To eovj�R oo�
.KUYY 01LEA3B BAMBS IN PLACL.
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L BAC KR FL D R UN 5 A C K
01D
BXCB$SIVB SOLIDS FLOODED
-SOLrD CAKRYoY9R,'—,., 07"HER EXPLAIN
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THf S PJ1. L., IN iTNUEf" AS A'W44\M—,) OF 7q, St 'J'VL'�
FW.V,*Ti,:Xi rl F �C.ATION Nt LLU i'l Cf . F) R,F, KNA iN Se, I
AND ASSOC-
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THIS f -j 1, IS f�,- 7 IN fR4j�
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FAIL
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sEMC SISTEH
INSTALLATICK CHECK LIST
LOT
EXCAVATION OK FAIL
1/4y_
1. Distance To:
a. Wetlands
b. Drains
c.. Well
2, Water Line Location
3. No PVC Pipe
4. Septic Tank
a. -Tees r. -Length & To Clean Out Covers
b. Cement Pipe to Tank .- On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6.. Leach Field or Trench
a. Dimensions
b. Stone Depth
e 0- Capped Bads
d. Clean Double' Washed Stone'
7. Leach Pits
a. Dimensions
b. Stone Depth
e. Splash Pads
d. Tees
e. Cement Pipe to Pit Both Sides
f. clean Double Washed Stone
8, No Garbage Disposal
9. -71nal. Grading lnspecti.=7-��
10. &-irricading Covered Systen
11. As Built Subnitted
a. Lot Location
b Dimensions of System
c: Location witll Regard_to Pere Test
d. Elevations
e* Water Table
Boara Of Health
!mdov-er,,YaZjs
APPROM.,
Provide,do-
snsum?An DISPOSAL DFM2? CHECK LIST
DISAPPRUM DATE
Rea.sons:
LOT
Title V_ FAIL CK
Reg 2.5 The submitted plan must show as a minim=:
the lot to be served-areajdLmensions lot # abutters
location and log deep observation holes-di'stance to ties
location and results percolation tests -distance to ties hin ea
design calculations & calculations showing required lear- 9 ar
ocation and dLmensions of sys tem-imlu ding reserve area
existing and prcposed contours
g) location any vat areas -Athin 1001 of sel.-age disposal system or
disclaimer -check wetlands napping
h)* surface and subsurface drains vithin 1001 of sewage disposal
system or disclai.,�
�J) location any drainage easenents 14thin 1001 of se-.sge disposal
Ksystem or disclaimeer-Planning Board files
J) jmo.�,n &oumes of vater sup p-ge disposal a
system or disclainer ply -within 2001 of se,
CL -loo, fmm leaching facil
-loocation --of any- propo red vre.!I_J�0 _.9.erY__ej t I
location of .ster lines on property -101 from le -aching facffiij�
location.of benchmark
drive,,,-ays -
-garbage disposals
no PVC to be used in construction
q) profile of -systen-elevations of basement., plunb., pipe., septic tank�
distribution box inlets and outletsj, distribution field piping and
Otter elevations
maximmm ground water elevation in area sewage disposal system
s) plan must be prepared by a Professional Ragineer or other
professional authorized by 1,-aw to prepare such- plans
Reg 6 SETILC Tanks S3 deptb of teesv
a) capacities-150%'of flow.,, -water table., tee
accersq pul�pinL7
(b) cleanout, uDd P001
�1_(c) 10 1 from cellar jmll. or ingro
1r(d) 251 from subsurface 6.r&Jns
Reg 10.2 ;, Distribution Boxes
0�a) slope g-,� �tt�hasn 0.08
b) gunp
Reg 10.4
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SOIL PROFILE & PERCOLATION TEST DATA
3
North Ahdoverq
Mass. Street No
ru-Ildle Jow- ey.T-
—Lot No
Loc/Subdiv.-
L4
Pland Owner
ozi.-y C -CM,
Investigator
Observer
SOIL PROFILE DATES
Start 7'est=71me
1."Elev
2.Elev
3.Elev
4.Elev
L
Drop of Y -Time
0.
0
0
0
Drop of 6" -Time
1,—
-Tj S
1
-T
1
Ydns.2nd 3" Drop
Percolation
Ti -es to -Test
Pits
2
2
2
2
3,
3
3
3
4
4
4
4
5
6
7
8
9
10
DATES
5
6
7
8
9
10
—Location
Datum
PERCO;ATION TESTS
I- I Z;Ae
5
6
7
8
9
10
Pit Number
1
2
3
Start Saturation
10 *. t4
L4
Soak -Minutes
Start 7'est=71me
L
49
Drop of Y -Time
Drop of 6" -Time
Yjd�ns.lst 311 droV
Ydns.2nd 3" Drop
Percolation
lil i7
16 e
S'l' !NL�T 17
" f UK)
ST Qij'rLi�T
D (�'(lx It I U
-;L�T
(qg r
I CERTILY ',hr,'F iW SFFTO�'-- SC,71W ,A!� A, 'JICASN
THIS F, -Ali 1�-) INTEMIEPAS A'vV'4-+AN n-' 017 -,FF 'I�Yi Ff.�,
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IENT COD.
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Dist
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L0 CAT I C "I - LD -1 4
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DATEE 7-25-6 F
PREPA RE U 6 Y
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