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HomeMy WebLinkAboutMiscellaneous - 151 RALEIGH TAVERN LANE 9/29/2015 (2) W c d z o z E p LL W O J N W_ I— a 3 ° O Z w =3 Z N C O L N vb = a > U LA U Q J v^i Q W W oZ ° -- LL a Q p N L> a� Q cj� Z O O o m 3 v O O J O 3 f 3 ur) O Q2 o Q O (1) F- o c un N ro rd Q i N Z � — N '' tYyn C rd O U O v bA J ro N� U N,NOy rrw Q N Q.. N 1i. -... ._ _. r FORM 11 - SOIL EVALUATOR FORM Page I of 3 Date: Commonweal h of Massachusetts Massachusetts Soil Suitabili Ass S8 entf—o—r —Qn- ---S ---ge _Dvisposal iite —ewa Performed By: .... .................... ... ........... Date: ...........I...................................... ................ Witnessed By: ...-- --- ;1111 -T- 0,aw's ley/1 t tx=tjon AddfCSS Or I""'•" / La A-51 Z'q ow Tekphonc I 1"ve. ew construction ❑ Repair Office Review Published Soil Survey Available: No Yes -c6,4c5) Soil Map Unit year Published ............ Publication Scale .... ........... - .4 &.M. -,2 ............................................ ............. oil Limitations Drainage Class : No ❑ Yes ❑ Surficial Geologic Report Available Year Published Publication Scale ................................... ........... Geologic Material (Map Unit) .. ................................................................... ......... ...... Landform ......:::::.......................... .................. Flood Insurance Rate Map: Above 500 year flood boundary No Dyes 0 Within 500 Year flood boundary No Oyes ❑ Within 100 year flood boundary No D Yes ❑ WeilandArea: Map (map unit) ............................................................................................ National Weiland Inv entory Map (ma unit) ......... ....................... ................. ............. .......... Wetlands Conservancy Program M p Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal ❑helcw Normal Other References Reviewed' DEP APPROVED FORM•12/07/95 • 1 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review a /9,7 //Deep Hole Number Datea Timer Weather Location (identify on site plan) S�DiuT/. G Slope Surface Stones Land Use ,.C .•• Vegetation Landform Position on landscape (sketch on the back) Distances from: D Open Water Body -_?00 feet Drainage way feet Possible Wet Area .4�0 feet Property Line .`2 feet Drinking Water Well feet Other :. ...::.:..:.:....:.::.::::.:..:.. DEEP OBSERVATION HOLE LOGr Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, o - S Z,6 � C� EA �`�(� �%� DepthtoBedrock: Parent Material (geologic) _�� _- Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: -- Estimated Seasonal High Ground Water: -r°� — DEP APPROVED FORrrt-12/07195 FORM 11 - SOIL EVALUATOR 1�ORNI Page 2 of 3 Location Address or Lot NO. On-site Review 6 Deep Hole Number Z... Date:.�� ��Q/ Time:�l �5 WeatherAl-';—�'- Location (identify on site plan) Land Use .. �Tr�'QL Slope (%1 Surface Stones ) Gl��= .. :.::..,.::...:. . .:.... . Vegetation . ...::. -.... . Landform Position on landscape (sketch on the back) ..7�� .... Distances from: Open Water Body � feet Drainage way feet Possible Wet Area feet Property Line ... ............ feet Drinking Water Well .:.:: feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) ,y� Parent Material(geologic) -% G�� /v �� DepthtoSedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: -- DEP APPROVED FORM- 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review Deep Hole Number _ Date/ Time:// �'� Weather J/� • Dom... .:. �Z..::..:............::.::....:...:..:......_.:,. .:..:::._.::..::.::.. . . . .. ..:.:.... .... Location (identify on site plan)—: 4 _. �.:.• - - °°° Land Use ...� Slope (%)�' ' L Surface Stones !¢' Y Vegetation .. � ................ .:...... Landform .... ..:. . Position on landscape (sketch on the back) Distances from: 24� Open Water Body � -0 feet Drainage way_ feet Possible Wet Area 2 feet Property Line ..Z feet Drinking Water Well . ::" feet Other :. . ............ ,"..,..:::::..:..:,.. DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mottling (Structure,Stones, Bould)rs, Consistency, Gravel ev :17r)TT EVM7TF. Parent Material (geologic) -7V DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole:— Weeping from Pit Face: Estimated Seasonal High Ground Water: I)EP APPROVED FORM-12/07195 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. .Determination for Seasonal High W&er Table Method Used: ❑ Depth observed standing in observation hole... ............. inches ❑ Depth weeping from side of observation hole ............ ... inches © Depth to soil mottles ....` inches �� Z 5"z ❑ Ground water adjustment ................... feet 3 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? No If not, what is the depth of naturally occurring pervious material? Certification I certify that on (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 390 CMR 15.017. Signature `-- ' ✓ Date DEP APPROVED FORM• 12/07/95 FORME 11 - SOIL EVALUATOR FORM Page 1 of 3 No.—a// Date: p8 Commonwealth of Massachusetts A� Massachusetts Soil SuitabWo Asseament for On-site Sewage ,Dis,posal Performed By: ..... !......................... ........... Date: ���` Witnessed By: Xi ............... 1 ............ ......................... ................... ................. _.. ............. .. ........... �...... Locstton Address or Ovner'$Nam, W N m F Address,and Tckphone/ ✓, �� ��'1 ew Construction ❑ Repair 2' Office_Review Published Soil Survey Available: No ❑ Yes d ... Publication Scale. Soil Ma Unit �-,�- ......... Year Published ����....... � <.................. p Drainage ClasscOA�- 2PI Soil Limitations ........ ........................... _...................._....,.... Surficial Geologic Report Available: No ® Yes ❑ . Year Published ....1.....:... Publication Scale ,.......,.v— , Geologic Material (Map Unit) ............................................................................I..................................__............ .......,................ Landform ....................................................................................................................................................................._............. ..__......._._....__.... a 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 /190• Range ;Above Normal ONormal ❑Belciv Normal ❑ Other References Reviewed: DEP APPROVED FORM•12107/9S FORM It - SOIL EVALUATOR FORA Page 2 or 3 Location Address or Lot No. 1_43-1 C,�/�� �1��/�k-69 Alm. On-site Review Deep Hole Number Date: ✓/�� Time:.. .,: Weather Location (identify on site plan) ®. �.° ,,..?�� n...... Land Use `'ZO. ...L Slope (%? Surface Stones —.:...:.v:. Vegetation : . . .: 5. :. .w. Landform ..::.!�./af :..:............ ..,h. Position on landscape (sketch on the back) .. ...:: . . .-.. :. Distances from: a Open Water Body .` M57 feet Drainage way.�'�.. feet Possible Wet Area �'`�. feet Property Line .. . .......... feet Drinking Water Well feet Other . .. .......`....,k ... , DEEP OBSERVATION MOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) © •�� �8 T"/G L �.ice �/vim 5 Z' Parent Material (geologic)'dGl�l� 7� _ DepthtoBedrock: Death to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Esjimated Seasonal High Ground Water: �/ DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORNJ Page 2 of 3 Location Address or Lot too Qn-site Bev�ew Deep Hale Number .;�....... Date: /.. Time:/ WeatherC��+�� G Location (identify on site plan) �`�.,. >4. Land Use Slope M Surface Stones .:. Vegetation Landform Position on landscape (sketch on the back)''::..: .. .._,... .,, Distances from: Open Water Body . �� feet Drainage ways`` feet Possible Wot Area feet Property Line .. feet Drinking Water Well ....7. feet Other .. .__ DEEP OBSERVATION HOLE LOG` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) 7- -f S MINIMUM UP 2 HOLES REQUIR D-AT EVERY PROPOSED DISPOSAL AHEA // Parent Material(geologic) �� _ �`� DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: '' Weeping from Pit Face: Estimated Seasonal High Ground Water: ,..T._ DLP APPROVED FORM-12/07193 FORM 11 - SOIL Lti'ALUATOR FORM Page 3 of 3 Location Address or Lot No. e ermi anon or Seasonal Hi-9 h ater Table Method Used: ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side of observation hole..,.... inches ® Depth to soil mottles ....: inches �....,..�o ❑ Ground water adjustment .......I........... feet ZW,4,-'t- Index Well Number .................. Reading Date .................. Index well level .. ........ ... Adjustment factor .,................. Adjusted ground water level ..... De th of atu all Oc urrin Pe vious Material Does at least four feet of naturally occurring observed throughout the area proposed for th pervious oil absorption system? �n a�areas If not, what is the depth of naturally occurring pervious mater ial w Certification I certify that on , �5 (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 16.017. Signature ��2GC Date DEP APPROVED FORM•12/07/95 � � N U co oD CQ c Oo co -j -v v co r I I t} t 5. "0 '\I Aij N-1- X4"' i Aff b I �Y d r ATE: ® � LOCATION: S !W ENGINEER: ��' BOH WITNESS: PERCOLATION TEST# BOTTOM DEPTH OF PERC TEST: 2 0 C� TIME OF SOAK: ; (At least 15 minutes long) TIME AT 12" r` TIME AT 9" r TIME AT 6" OVERNIGHT SOAK 1 TIME STARTED ( ;_ NEXT DAY SOAK: r ", / (At least 15 minutes) n� � TIME AT 12" 8 L, TIME AT 9" 1 TIME AT 6" DATE: a LOCATION: ENGINEER: BOH WITNESS: c�c�� PERCOLATION TEST# - BOTTOM DEPTH OF PERC TEST: , a TIME OF SOAK: ° (At least 15 minutes long) TIME AT 12" � . TIME AT 9" TIME AT 6" OVERNIGHT SOAK TIME STARTED � O t- - S NEXT DAY SOAK: 7 , �` 0 t� (At least 15 minutes) TIME AT 12" 6 TIME AT 9" e TIME AT 6° �-�-S DATE: `0 LOCATION: ll ENGINEER: BOH WITNESS: J�,'"ad i PERCOLATION TEST# BOTTOM DEPTH OF PERC TEST: r== TIME OF SOAK: (At least 15 minutes long) TIME AT 12" TIME AT 9" TIME AT 6" OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: (At least 15 minutes) TIME AT 12" TIME AT 9" TIME AT 6" I C_N Commonwealth of Massachusetts _ City/Town of North Andover System Pumping Record SU" U 2 2014. Form'4 wflwtllff DEP has provided this form for use by local Boards of Health. Other forms may be us e ; b `"the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1 j J A�' // key to move your Address cursor-do not North Andover Ma 01886 use the return City/Town State Zip Code key. 2. System Owner: P sue- Name return Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �� — 2. Quantity Pumped: Callon Date 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If Yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record-Page 1 of 1