140 Septic Perc Test 2010 Important When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
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Commonwealth of Massachusetts
City/Town of
Percolation Test
Form 12
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. 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
the local Board of Health to determine the form they use.
A. Site Information
F sr_
Owner Nam6
1' O CAl,tc tMtadb-7 Qond
Street Address or Lot#
oYT onehr-
City/Town
MB
State
Contact Person Of different from Owner) Telephone Number
omb0
Zip Code
B. Test Results
Observation Hole#
Depth of Perc
Start Pre-Soak
End Pre-Soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate(Min./Inch)
Test Performed By:
Witnessed By:
Comments:
Ocb\atr TL�7eJ' ocwbc' 12t7A1a
Date Time Date Time
OD 6A' 1)ns /vii
Test Passed:
Test Failed:
Test Passed: ❑
Test Failed: ❑
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