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HomeMy WebLinkAboutMiscellaneous - 12 FARNUM STREET 10/7/2015 I, Commonwealth of Massachusetts _ City/Town of J System Pumping Record e, Form 4 s I 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 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. i" A. Facility. Information 1. System Location: Left/Right front of house, Left!Right rear of hous. Le,CYig sid of hamus ; Left/ Right side of building, Left I Right front of building, Left/Right rear of building, Un er deok Address Citylrown State Zip Code 2. System Owner: Name Address(if different from location) Citylrown ' State -— Zip Cod Telephone Number _ 1 B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No, 5. Conditi " o System: ' 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Lo oite contents were disposed: (. L S. Lowell Waste Water 1�4 SignAtule ct Haule Date t5fomr4.doc•06/03 System Pumping Record•Page 1 of 1 i i i � � p;r r 11 +4/�`! � Z dt�r M✓�� lidil 141di� ,?!l/dy7,�+ I,+r�,f5j � a � t ,.f� S+ tit t 1 OF NO RT SYSTEM PUM,pr,mc . COR-J .yl'�-16M UWNFR*& ADDRESS , SYSTEM LOC'aTION - bOr (ez�mPle; iQf( from of hoar) rAq'iY) , - -� ' r , U IrG UF`PUMP►Nq; (QUANTITY f'UM GD i �t r :� lb Ord!? .•.:," +ay�' � i l�xi }�'' y ,i.,.�:. r / �.'I,a,�l'UUL `N0 YhS SEPTIC TANK; NO YES �'. TUKE` OFSERYI'CE, ROUTINE EMER0EN'CY „U„OVp';CUNL?11'ION ` h'ULL'T0 COY C, k. �I Y CR ;rtSD” .13AFFLLS IN ))'I,ACl LFACHFIiaLD IZUNUaC'K.r, -- CXCFSSIY SQJ✓!DS FLOODED' 50LIp,5;CARliYOy R ,' p HFR (� Xrl,a.IN) K+tt�'.j'Y�t}ail"trrr f��ti• +t+U�) .tar ti tt v e +j { ,i q it{I!Y;y{{" rfitj.�} 1 ��{ I,' r r � r51`� ` •I M :PrUM ('Cl�f.pYr, "� r tir , r,NTS� dd r A�{�{ 'Tt 'l USN I'Iih''I'�' �I'IZANSl'GI�I� "D t1`U;'' . .�-,'. r. r?!Y 1'.....,f,f.. i �1{llir ',li•}.'r.�IN ! ...,���,1:� i� r . ,. �F�1T� �1JD vs h�ASSACQ Ord I vEP ha; ��D VflJ84 �h�� r��(�) �' I i 'Cut �0 1'J7(1;(((Oa lO 1110 10, ai , d � .. c Ju.UI Or C:hpt A. Fac111ty Infornlat,!,:)n -- Maw r2. rS71l�mpwnOr Son Man OfMorml rwn lOC-0nn B,.Pumping Reyord J() 3 Tyra 01 ey)lam, Saplc ra t. ��-O�ner (�+ascnba�, a EiTya , as Fllla pr�sanrr� `',,o5 9 ,,Coridl�Jonl Y Pvmm 6C, LM 4 C w I.���d�� t���� �Ij� `� �}' � � � U9h1G�9 - -- oQn wh r e e corl(enls were cl9p�sew 01 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the individual subsurface disposal system constructed ( ) or repaired (x) by North Andover Licensed Installer John Soucy at 12 Farnum Street, North Andover, MA 01845 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit Number 997 dated April 21, 1998. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector FROM SOUCY'S SEWER SERVICE INC* PHONE NO. Aug*. 26 1998 08:51PM P2 TOWN OF NORTH ANDOVER SEWAGE DfSPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage a DisposM System ) constructed; ( zcpaired; by c lUfd(�G located at Lr-41j1--r) was installed in conformances with tho:N o'xthiAutlovet Board,o.,He alth approved plan; System Desi&a Pexwit 4—< dated �`/ , with an approVed design flow of pa(:lons:per:day. The materiahs'used were in coormamce with those specified on the approved plsn;�the.system was i stallediu-accor&nce with the provisions o f-31-0 CMR 15.000, Title S aad loea3:regutations, the final gradiiig'ig= substantially vwA the approved plan. All work is courateZ ;repre� ed on.,tk s�built tivhiclx k�a$been subinitCl to the Board of l lealth. Date: tk OF ift esigxa Fn eex' 51� I AS-BUILT CHECI{LIST � *" LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS . LOCATION & DEMENSIONS OF SYSTEM, 5 INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA ! LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK& D-BOX STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW FINAL CONTOURS ' LOCATION & ELEVATION OF BENCHMARK USED LOCUSPLAN i 6 Town of North Andover, Massachusetts Form"°•s BOARD OF HEALTH f NORTH 1 3? p�tn•. ..'e OG � � -19 O m F A "Al.o.��"� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSC' Applicant., �Lka ( 1'-)L1 C-61 NAME ADDRESS TEI FP190NF Site Location ,/ Permission is hereby granted to Construct ( ) or Repair ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, 90ARD OFHEALTH Fee j D.W.C. No. f APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: kcd� LICENSED INSTA ER: cc �tc SIGNATURE: v, TE PHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes- No Foundation As-Built? Yes No Floor Plans? Yes„ No Approval ;% Date: i i Town of North Andover, Massachusetts Form No•a „oRTti BOARD OF HEALTH o ,,"• tio c 19 / 3� •' p DESIGN APPROVAL FOR ,SSA CHU SOIL ABSORPTION.SEWAGE DISPOSAL SYSTEM Applicant - t�°°n`.�—° '°- ' Test No. Site Location ea- Reference Plans and Specs. �✓'`` -5�l ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of'Board,of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. Vq7 Town n ®f North Andover er * p40RTH .4 OFFICE OF 3�O ct t e o tiO L COMMUNI'T'Y DEVELOPMENT SERVICES � A 30 School Street Z WILLIAM J. SCOTT North Andover, Massachusetts 018�45 sSncHUS�t�� Director April 22, 1998 Ben Osgood, Jr. New England Engineering 33 Walker Road North Andover, MA 01845 RE: 12 Farnum Street Dear Mr. Osgood: This letter is to inform you that the proposed septic plans for 12 Farnum Street have been approved. If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerrelyy,,� Sandra Starr, R.S. Health Administrator cc: Wm. Scott, Dir. CD&S Tony Randazzo File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 114EW ENGLAND ENGINEERING SERVICES .._._.............._._._....._...... I N C March 21, 1998 I Sandra Starr, Administrator North Andover Board of Health 30 School Street f North Andover, MA 01845 Re: 12 Farnum Street Dear Sandra: Enclosed are three copies of a new septic system design for 12 Farnum Street in North Andover. The owner requested that we redesign the system using the area of the existing above ground pool. The pool will be removed. This design requires a local upgrade approval for a reduction in the offset distance from the water table from four feet to three feet. No other local upgrade approvals or local bylaw variances are needed. The Board of Health approved the groundwater offset for the previous design. If you feel that that approval can be used for this plan then no new hearing would be needed. If you feel that the old approval can not be extended to this plan then I hereby request a hearing for the local upgrade approval. If you have any questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., EIT 33 WALKER RD, _. SUFFE 22 - NORTH OVE , MA 01845 -- (508) 686-1768 ' I PLAN REVIEW CHECKLIST ADDRESS_ _/, '/l/ J/l I ENGINEER 666 6 GENERAL 3 COPIES C °' STAMP LOCUS ~ NORTH ARROW Z--" SCALE °" µpY CONTOURS PROFILE ./-~'� (Sc) SECTION L.-- BENCHMARK � � SOIL & PERCS d _. ELEVATIONS "" WETS . DISCLAIMER WELLS & WETS WATERSHED?J/6 DRIVEWAY ,-' WATER LINE L FDN DRAIN M&P SCH40 aA,.. TESTS CURRENT? c:_...- SOIL EVAL /�J� /') /C, 1j SEPTIC TANK - MIN 150OG �- � . 17 INVERT DROP L GARB. GRINDER_SL(2 comps +200) 10 TO FDN MANHOLE l ELEV GW # COMPS . GB D®BOX SIZE # -LINES FIRST 2 ' LEVEL STATEMENT OUTLET 2�d j,2-� _ - 17 (2" OR . 17 FT) TEE REQ'D? r . ..m /;7 LEACHING MIN 440 GPD? RESERVE AREA 4 ' FROM PRIMARY?­ " 2% SLOPE �,....m 100 ' TO WETLANDS 100 ' TO WELLS 4 ' TO S .H.GW (5 ' >2M/IN) 20 ' TO FND & INTRCPTR DRAINS ~J 400 ' TO SURFACE H2O SUPP �W 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? -''✓( 15 ' ) BREAKOUT MET? , TRENCHES MIN 440 gpd SLOPE (min . 005 or 6"/100 ' ) U,~ "SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) RESERVE BETWEEN TRENCHES? —' IN FILL? L./l MUST BE 10 ' MIN. ,° 4" PEA STONE? VENT? 1 - (>3 ' COVER; LINES >501 ) BOT J + SIDE J _ J X LDNG = TOT ( L x W x #) (DxLx2x#) (G/ft2) Copyright © 1996 by S.L. Starr " i NORTH ANDOVER BOARD OF HEALTH / DESIGN REVIEW REPORT DATE ,/-- FEE: PERMIT # �', DATE RECEIVED APPLICANT MAP /G PARCEL ` f. y/ f(,�'�d. ` LOT # STREET # ADDRESS / �:. ENG. � STREET r1" /'i°., t` / ✓®` .w ENGINEER ' S ADD ./ PLAN DATE 7 REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL : y Id 7 19 w /�/�� _ ............... NEW ENGLAND ENGINEERING SERVICES INC .....................W....._._._.. January 24, 1998 Sandra Starr, R.S., Health Administrator North Andover Board of Health 30 School Street 6 North Andover, MA 01845 .......... Re: 12 Famum Street septic design Dear Sandra Starr: The purpose of this letter is to address the comments contained in your letter dated December 31, 1998 regarding the septic system design submitted by this office. Responses to each of your comments are listed below. 1. All of the distances required are now shown. 2. The system is designed to be 70 feet from an isolated wetlands. A variance to the North Andover Health Bylaw has been requested to allow construction of the system 70 feet from the wetland in lieu of the required 100 feet. This design meets the Title 5 requirements, 3. The leach trenches are designed 6 feet apart in lieu of the required 10 feet in the North Andover Health Bylaws. A variance to the bylaws has been requested. This design meets the Title 5 requirements. 4. The bottom of the leach trenches are designed to be 3 feet above the groundwater in lieu of the required 4 feet. This is allowed as a local upgrade approval. A local upgrade approval is being requested for this item. 5. The pool is above ground and has been labeled as such. 6. The soil class data has been corrected in the notes. 7. A note has been added indicating that an additional test is needed prior to construction. I will be at your February Board of Health meeting to discuss the variances that are being requested. If you have any further questions please do not hesitate to contact this office. Yours truly, Benjamin C. Osgood, Jr., FIT 33 WALKER RD. -- SUITE 22 NORTH ANDOVER, MA 01845 (508) 686-1768 ............... .......... Town of North Andover y T� OF 1710E OF 0 COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover,Massachusetts 01845 cgwu��"�� WILLIAM J. SCOTT Director December 31, 1997 Ben Osgood Jr. New England Engineering 33 Walker Road North Andover, MA 01845 Re: 12 Farnum Street Dear Mr. Osgood : This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. Distances not shown (N. A 8.03). 2. Less than 100' to wetlands (N. A. 5.02). 3. Trenches less than 10' apart (N. A. 14.01). 4. Less than 4' to groundwater (3 10 CMB 15.212). 5. Is pool inground? If yes, leach area less than 20' (3 10 CMR 15.211). 6. Soil class type in design data incorrect - Class I. 7. Need additional deep @ East end of system prior to construction. If you have any further questions, please do not hesitate to call the Board of Health Office at the number listed below. Sincerely, Sandra Starr, R.S. Health Administrator cc: Tony Randazo William J. Scott, Director, MCD File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Town of North Andover of ORTH OFFICE OF O? ycs��eo COMMUNITY DEVELOPMENT SERVICES 0 p 30 School Streets North Andover,Massachusetts 01845 WILLIAM J. SCOTT SSACHUSE Director December 31, 1997 Ben Osgood Jr. New England Engineering 33 Walker Road North Andover, MA 01845 Re: 12 Farnum Street Dear Mr. Osgood : This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1. Distances not shown (N. A 8.03). 2. Less than 100' to wetlands (N. A. 5.02). 3. Trenches less than 10' apart (N. A. 14.01). 4. Less than 4' to groundwater (3 10 CMB 15.212). 5. Is pool inground? If yes, leach area less than 20' (3 10 CMR 15.211). 6. Soil class type in design data incorrect - Class I. 7. Need additional deep @ East end of system prior to construction. If you have any further questions, please do not hesitate to call the Board of Health Office at the number listed below. Sincerely, Sandra Starr, R.S. Health Administrator cc: Tony Randazo William J. Scott, Director, P&CD File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNNG 688-9535 t 3 Y M' � 4 1 f F I . h Sal IME IM M SWIM _-_----IM INN ........�I.�... ..�.� IM lM IM IN IMEM �IM ti IM IN Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH ,�%O RTH 0 0 19 0 APPLICATION FOR SITE TESTING/INSPECTION "'�ATM P?" ITS CHUS Applicant— TELEPHONE NAME ADDRESS Site Location -)U0 A-Y V - Engineer A — &t rte ADDRESS TELEPHONE NAME 1A Test/inspection Date and Time -,J997 CHAIRMAN,BOARD OF HEALTH H Test No—g,�lze '72 Fee S.S. Permit No._D.W.C. No.—C.C. Date—Plbg. Permit No.— 0,1 1 1 1 1 ii Milli lil'illillil:mmmmmmmuMEMMMEMMMMMM pORTIy , Of a BOARD OF HEALTH r 146 MAIN STREET TEL. 688-9540 �. t5 'SSACHU5£� NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: -; 2 31 q`7 LOCATION OF SOIL TESTS: Assessor's map & parcel number:_1 -7 1: I-01- y'l OWNER: '- WNER: ' c 2 0 TEL. NO.: ADDRESS: / 6Z ENGINEER: TEL. NO.: So 0 CERTIFIED SOIL EVALUATOR: �� cj•� % �� 1 �. Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than V-1 shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. d 1, i ?� d V 7Z,71--7/ 1 '. I apt DATE: C C LOCATION: ENGINEER: BOH WITNESS: PERCOLATION TEST# BOTTOM DEPTH OF PERC TEST: m TIME OF SOAK: �� `° 1 F'.: ' / (At least 15 minutes long) TIME AT 12" % % �L5 TIME AT 9" Z TIME AT 6" `( OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: (At least 15 minutes) TIME AT 12" TIME AT 9" TIME AT 6" NEW ENGLAND ENGINEERING sEavicEs, INC. [LffffEff[En 33 Walker Rd. Suite 23 NORTH ANDOVER, MA 01845 DATE iOg NO. PHONE (508) 686-1768 FAX (508) 685-1099 ATT � TO ~' � � r � RE: 1 . > ll WE ARE SENDING YOU Attached ❑ Under separate cover via the following items: ❑ Shop drawings * Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION j/ L1147 '_ / 44— w THESE ARE TRANSMITTED as checked below: For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS �* ' d" ` s�f ..., .. '_-i to.. 6r f 4- r'" ,a"r G fig^ %L.P"d°.R'A"6"1 '7/� �✓'6 0 COPY TO � _ SIGNED:— —L if enclosures are not as noted,kindly notify us a once. - -- nCT. 28. 1997 4:^6Phl P R - ANG RD PHOIAE 1,10. 617. 3 4 Gt11 FORM 11 - SOIL EVALUATOR i,'oHm Page 2 of 3 i,,,ocstion Address or Lot i4o. ��.�/(�� fir, mod• , �/Ail 'f� On-sate Re vie w Deep Dole Number Date: .. /q� Timer:& ! "1. Weatherl�'�� Location (identify on site plan) ' . ,. .. Land Use ...... ' r� Slope t°r6) . .� Surface Stones Vegetation _ Landform �� :../? ` 1 ¢�i,E :. . ....::... . . . .......,:..,. :. Position an landscape (sketch on the back) ... . . � Distances from, Open Water Body feet Drainage Way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other .. ... DEEP OBSERVATION HOLE LUG' 4 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, k9 Yle ,(� GrdveQ dam' .. �- �• .�— �'�iL .l 10 o Parent Material(goologlc av,)W l" Deathto Groundw8tor: Standing W ter in the Hole: Weeping from Pit Face: EB>;imated Seasonal High Ground Water: UEP"PROVED FORTf- 12/07/95 DRAFT 1997 4:3EPM P`2 '—FROM R:C• TANGARD PHONE H0. 617 7-34 01115 FORM 11 SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 1c2 o/l AA7• on-site eview Deep Hole Number .. . . Date:_�`� 1lme:..//'.:...: Weather Location (identify on site plan) ...! ¢ j/ ;..: .......: ... _....:::.,.........:._ Land Use .... �� 11r�� Slope (%) . ..�:. . Surface Stones Vegetation . ..,... :.:., :. .. Landform < (sketch„ Position on landscape on the back) 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” J� Dopth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure, Stones, Bouldars, Consistency, % Gravel) . �� �/ � nom'✓�/ �r�MC�I ,f��, / � � � P1v"F_41 Parent Mbtarici (0-109101 <fC— 4 �4 4" Oapthtoeedrock; Qg_oth to GroyDjMkter. Standing Water in the Hole: _ Weeping from Pit Face: Espmated Seasonal High Ground Water: ---.-------- ---- DEP APPROVED FORM-12/07/95 P17 AFT FORM 11 - SOIL EVALUATOR FORM Inge 1 or 3 No, . t Date;Aa} q Commonwealth of Massachusetts Massachusetts I r On-site Se , r� ,ll�r m C C oZ // Performed $y: ,....... .�.. ...••.....•,,.,.. .,.,,., .��.,�... 3333. Date: Witnessed . .............. . . ....R .'..,,....•... ....•,.......•,. •... 3333 .,.., .... .....,..... ,....._.,....-.,......... Loation A*ft4#Of 1,2— LIM I moo, Ar lX AA*«. Tom, ew GonsMctlon ❑ Repair L� lTc Published Soil Survey Availablo: No ❑ Yes Year Published / �� ....... Publication Scale Soil Map Unit 3333 Drainage Class AEG- •<K Soil Limitations ;Z�yep/p...... .......... . SwTjoial Geologic Report Available: No Q Yes Year Published Publication Scale ...,�� GeologicMaterial (Map Unit) .......................................................................................................3333.. L,andfonm ................................................................_.............................................,................................................. ...... Flood Insurance Raio Map: Above 500 year flood boundary No ❑Ycs Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland .A ma: National Wetland Inventory Map (map unit) ....... ............................ Wetlands Conservancy Program Map(tom unit) ................. .............................. ._.......... Current Water Rosourco Conditions ((JSGS): Month Range .Above Normal ❑Normal ❑Bolow Normal � Other Rnfbronoes Reviewed: —� DEP APMo"M FORM•IA/07195 DR�%F -- FiC.T. -. 1,:q97 4:-7,cp''. . F FROM R. C. TANGARD PHOI IE NO. 61? 3334 01115 FROM R. C. TANGARD P!BONE 0 , ,: '61.7 33 FORM 11 / - I SOIL EVALUATOR t'OIZM ]page 3 of 3 Location Address or Lot No. ei7 _ Determinatz'a r egynglyl dy �Yater ]'able )Method s d• ❑❑ Depth observed standing in observation hole................. inches Depth weeping from side of observation hole inches Depth to soil mottles ...._.,. inches ❑ Ground water adjustment feet -fix Index Well Number ................. Reading Date ............__ Index well level Adjustment factor ................... Adjusted ground u water level ,;,,,,,,,,,,,. Depth of Naturally Occurring Pervih�s Material Does at least four feet of naturally occurring observed throughout the area proposed for th p soil absorptionrsystem? in all areas If not, what is the depth of naturally occurring pervious material? Certification certify that on + ` (date) 1 have passed the soil evaluator examinatia 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 �—r ate FT` . DEP APPRO'Y-W FORM.12/07195