Septic Form 2a - General Site Evaluation Data - Department Of Health & Human Services
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1Department of Health & Human Services
Division of Environmental and Consumer Health Services
Making It Better, Together
FORM 2A
GENERAL SITE EVALUATION DATA
1. Name of Site Evaluator (print): _______________________________________
2. Business Address of Site Evaluator: _________________________________________________
3. Business Phone Number of Site Evaluator: ________________________
4. Special Site Limitations Identified (Check appropriate Categories):
Flood Plains
Bedrock
Outcrops
Wetlands
Excessively Stony
Disturbed Ground
Sink Holes
Sand Dunes
Steep Slopes
Other—Specify ____________________________________
5. Soil Logs—Enter on Form 2b—Use one sheet for each soil log.
6. Considerations Relating to Disturbed Ground:
a) Type of Disturbance (Check appropriate categories):
Filled Area
Excavated Area
Re-graded Area
Subsurface Drains
Other—Specify _____________________________
b) Pre-existing Natural Ground Surface Elevation Relative to Existing Ground Surface ____________
____________ Method of Identification ________________________________________________
c) Suitability of Disturbed Ground
Unsuitable: Objects Subject to Disintegration or Change in
Volume
Excessively Coarse
Proctor Test performed
_______% Standard Proctor
Density = ________
7. Hydraulic Head Test:
a) Hydraulically Restrictive Horizon: Depth Top to Bottom ___________
b) Piezometer A: Depth to Bottom ______ Depth of Water Level (24 hrs) ___________
c) Piezometer B: Depth to Bottom ______ Depth of Water Level (24 hrs) ___________
d) Witnessed by ________________________ Signature ________________________ Date ____/____/____
8. Attachments (Check items included):
Site Plan
Key Map Showing Location of Site On U.S.G.S.
Quadrangle or Other Accurate Map
Key Map Showing Location of Site on U.S.D.A. Soil Survey Map
IMAP
Other—Specify __________________________________________________________
9. I hereby certify that the information furnished on Form 2a of this application (and the attachments thereto) is true and
accurate. I am aware that falsification of data is a violation of the Water Pollution Control Act (N.J.S.A. 58:10A-1 et seq.)
and is subject to penalties as prescribed in N.J.A.C. 7:14-8.
Signature of Soil Evaluator ____________________________________________ Date _____/_____/_____
_________
Signature of Professional Engineer _______________________________________ License # ___
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