Free 48100.FH11 - Indiana


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State: Indiana
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SOIL EVALUATION FOR ONSITE SEWAGE SYSTEMS
State Form 48100 (R / 10-08)

INDIANA STATE DEPARTMENT OF HEALTH
County

Reset Form
Date of survey (month, day, year)

Type of system:
Name of owner

Residential

Commercial

Address (number and street, city, state and ZIP code) Home telephone number Work telephone number Cellular number E-mail address

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)

(

)

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Name of person requesting assistance Address (number and street, city, state and ZIP code) Home telephone number Work telephone number Cellular number E-mail address

(

)

(

)

(

)

LOCATION OF PROPERTY
Address of property (number and street, city, state and ZIP code) Name of township Legal description Global Positioning Satalite (GPS) Latitude Name of subdivision Section Township Lot number Range

Global Positioning Satalite (GPS) Longitude

USE OR TYPE OF FACILITY
Stage of Development: Water supply: Public New (Planning) Private New (Under construction) Existing Proposed Existing System failure Change of use Clear Overcast Rain Snow Weather Conditions: _________ ° F

If Commercial, name of business Number of bedrooms Design flow considerations

Name of person(s) present during evaluation Availability of perimeter drain (show on site plan) Brief description of site and comments:

Signature of soil scientist conducting survey

Name of soil scientist conducting survey

IRSS registration number

Page 1 of ____ pages

SOIL EVALUATION FOR ONSITE SEWAGE SYSTEMS - SITE PLAN Site plan must include: Lot size, dimensions, configuration; direction of geographic north; roads and driveways; streams, ditches, ponds, lakes, bodies of water; location of all existing structures and wells; location of all soil borings from fixed benchmark(s). Show scale used.
County Name Date (month, day, year)

Page 2 of ____ pages

INDIVIDUAL SOIL PROFILE DESCRIPTION
County Name Date (month, day, year)

Equipment used Soil atlas number and date Map unit name Family classification Present land use Present vegetation Landform Landform component Modifier Shape of slope Coordinates (decimal degrees or NAD83, Zone 16) Site number and location DEPTH (inches) SOIL COLORS MOTTLES COATINGS

Slope ( % ) Slope aspect Surface cut or fill? Fill depth (inches) Wetness characteristics Depth to seasonal high water table (inches) Depth to free water, if present (inches) Seeps or springs? Ponds water

Depth in inches to Bedrock Fragic characteristics Gravel, coarse sand Dense glacial till Artificial compaction BC Horizon Massive-firm structure High shrink / swell Pressure faces / slickensides

HORIZON DESIGNATION

MATRIX

TEXTURE

CLAY (% )

STRUCTURE GRADE SHAPE SIZE

CONSISTENCY

CO. FR. ( %)

ROOTS (# / size)

EFFERPARENT VESENCE MATERIAL

Identify extent of areas of soil disturbance (cut / fill) on site map.

Soil Moisture:
Comments:

Dry

Moist

Near saturation

Frozen

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