140 Septic Soil & Perc Tests 2010 Commonwealth of Massachusetts
,.tt- _�, City/Town of
' ` -`v Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information
AntL-•. F(AS<n
Owner Names
- -- -- -� ---
NO Cptls •A<ccADLJ 12a„4
Street Address Map/Lot#
Norttnaw.p b.--. _ Ma a- _ e/24S____ .
City State Zip Code
B. Site Information
1. (Check one) ❑ New Construction ❑ Upgrade CSI Repair
2. Published Soil Survey Available? ❑ Yes ❑ No If yes:
Year Published Publication Scale Soil Map Unit
Soil Name Soil Limitations
3. Surficial Geological Report Available? ❑ Yes ❑ No If yes:
Year Published Publication Scale Map Unit
Geologic Material Landform
4. Flood Rate Insurance Map
i
Above the 500-year flood boundary? ❑ Yes ❑ No Within the 100-year flood boundary? ❑ Yes ❑ No
Within the 500-year flood boundary? ❑ Yes ❑ No Within a velocity zone? ❑ Yes ❑ No
5. Wetland Area: National Wetland Inventory Map ---- - - ----- - -
Map Unit Name
Wetlands Conservancy Program Map ---- -- ---- - - --- - •
Map Unit Name
6. Current Water Resource Conditions (USGS): Monthnear Range: ❑ Above Normal El Normal ❑ Below Normal
7. Other references reviewed: - --- - -- -- - - -
DEP form 11 •rev.1/10 Form 11-Sail Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8
Commonwealth of Massachusetts
q1— s City/Town of
1117 ! Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area)
Deep Observation Hole Number: --- ----- -- --- --
Date Time Weather
1. Location
Ground Elevation at Surface of Hole: - Location (identify on plan): - -- ---- -
2. Land Use
(e.g,woodland,agricultural field vacant lot etc.) Surface Stones Slope(%)
Vegetation Landform Position on Landscape(attach sheet)
3. Distances from: Open Water Body ------ Drainage Way ----- Possible Wet Area ---
feet feet feet
Property Line feed---- Drinking Water Well feet -- Other feet
4. Parent Material: --- --- - --- Unsuitable Materials Present: ❑ Yes ❑ No
If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Groundwater Observed: ❑ Yes ❑ No If yes: Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater: ------- - ------
inches elevation
DEP form 11 •rev. 1/10 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8
Commonwealth of Massachusetts
1 ;z City/Town of
f y Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
4x ,
C. On-Site Review (continued)
} )
1, OnA0 q- c, r. 5
L4..
Deep Observation Hole Number: -1 05 4 IL
Redoximorphic Features Coarse Fragments
Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil
Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other
Depth Color Percent Gravel Cobbles (Moist)
Stones
(c-Z2 13, 1 oy■
F
Additional Notes:
l , .
DEP form 11 •rev. 1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8
Commonwealth of Massachusetts
'era F, City/Town of
e'14' _' Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number: Dale Time weather
1. Location
Ground Elevation at Surface of Hole: - Location (identify on plan): - --- -_.
2. Land Use
(e.g.,woodland,agricultural field,vacant lot eta) Surface Stones Slope(%)
Vegetation Landform Position on Landscape(attach sheet)
3. Distances from: Open Water Body feet- --- Drainage Way feet Possible Wet Area feet -
Property Line reed Drinking Water Well feet Other feet
4. Parent Material: - - - Unsuitable Materials Present: ❑ Yes ❑ No
If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Groundwater Observed: ❑ Yes ❑ No If yes: - ----- ----
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater:
inches- elevation
DEP form 11 •rev. 1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8
Commonwealth of Massachusetts
r=_,ci City/Town of
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number: — °3
Redoximorphic Features Coarse Fragments
Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil
Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other
Depth Color Percent Gravel Cobbles& (Moist)
Stones
6- ñ 10`.(c I • I C) — _
C -eo gs l .Acl %
Z d <V C i 01 ft rr l'( \\ \ e( c c“v( cri. f4jAs
Additional Notes:
DEP form 11 •rev. 1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8
•
[4-e , Commonwealth of Massachusetts
ali City/Town of
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D. Determination of High Groundwater Elevation
1. Method Used:
❑ Depth observed standing water in observation hole A B.
inches inches
❑ Depth weeping from side of observation hole in
inches inches
❑ Depth to soil redoximorphic features (mottles) A. B_
inches inches
❑ Groundwater adjustment(USGS methodology) inches in
nches inches
2.
Index Well Number Reading Date Index Well Level
Adjustment
Factor Adjusted Groundwater Level
E. Depth of Pervious Material
1. Depth of Naturally Occurring Pervious Material
a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
❑ Yes ❑ No
b. If yes, at what depth was it observed? Upper boundary: inches __-- Lower boundary: inches
DEP form 11 •rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8
Commonwealth of Massachusetts
City/Town of
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
F. Certification
I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil
evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017. I further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form,
are accurate and in accordance with 310 CMR 15.100 through 15.107.
Signature of Soil Evaluator Date
_._..._.
Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam
Name of Board of Health Witness Board of Health
Note: In accordance with 310 CMR 15.01812)this form must be submitted to the approving authority within 60 days of the date of field testing,and
to the designer and the property owner with Percolation Test Form 12.
DEP form 11 •rev. 1/10 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8
-'\ Commonwealth of Massachusetts
;tr ,",9 City/Town of
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
Field Diagrams
Use this sheet for field diagrams:
DEP form 11 •rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8