192 Septic Perc Test 2010 Important:When
filling out forms
on the computer,
use only to tab
key to move your Owner Name
cursor-donut I�z r4-4 ,
use the ret rn Street Address or Lot#
key
City/Town
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
M Cie tc-C_
State Zip Code
Contact Person(if different from Owner) Telephone Number
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:
Date
1
53
Time
Date Time
9, 57
1 r7
IU vci
pia 7
Test Passed:
Test Failed:
Test Passed:
Test Failed:
t5torm12.doc•06/03 Perc Test•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
$:;-:1-1)) Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
,
C. On-Site Review (continued)
Deep Observation Hole Number: —�---.
Redoximorphic Features Coarse Fragments
Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil
Depth(in.) Layer Moist(Munsell) (USDA) Cobbles E. Structure Consistence Other
Depth Color Percent Gravel (Moist)
Stones
Zz- z1, % (4-
2 s5 ,(jti
SS •!ub
Additional Notes:
DEP form 11 •rev. 1/10 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8
st\. Commonwealth of Massachusetts
ftt- -(a City/Town of
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number: _--_- --- Date- Time Weather
1. Location
Ground Elevation at Surface of Hole: - Location (identify on plan):
2. Land Use -__- _ --
(e.g..wcotllend,agricultural field,vacant lot,etc) Surface Stones Slope(%)
Vegetation Landform Position on Landscape(attach sheet)
3. Distances from: Open Water Body reel Drainage Way root Possible Wet Area feet
Property Line feet 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 D Bedrock
5. Groundwater Observed: ❑ Yes ❑ No If yes: ---- - -- - -
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater: -- n - -----
inches elevation
DEP form 11 •rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8
l'\. Commonwealth of Massachusetts
City/Town of
k,t
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number - - --------
Redoximorphic Features Coarse Fragments
mottles %b Volume Soil
Soil Horizon/Soil Matrix:Color- _ t Soil Texture by Soil
Depth(in.) Layer Moist(Mansell) (USDA) Cobbles& Structure Consistence Other
Depth Color Percent Gravel (Moist)
Stones
Additional Notes:
DEP form 11 •rev. 1/10 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8
Commonwealth of Massachusetts
c City/Town of
tie" Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D. Determination of High Groundwater Elevation
1. Method Used
El in Depth observed standing water in observation hole in
inches inches
ID Depth weeping from side of observation hole A. - -
inches inches
El Depth to soil redoximorphic features (mottles) in
inches inches
❑ Groundwater adjustment(USGS methodology) A. inches ----
inches In
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
g:1= i City/Town of
i '' =F" Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
e.,r�e,U Y 9 p
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. 1 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 M Date of Soil Evaluator Exam
Name of Board of Health Witness Board of Health
Note: In accordance with 310 CMR 15.018(2)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
An --t ` City/Town of
rit 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
Commonwealth of Massachusetts b l '1 ' <>o(.1 1 V`
kI r`, City/Town of
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
1/4_
A. Facility Information
Ili- co \ez ,M9aan _toar•A Ml Ckakt__,,Iv,_ir/ {'S A-
Owner Name
Street Address Map/Lot#
_ _l i r c-i krYN r e. eiac, _. _.__ ...
City State Zip Code
B. Site Information
1. (Check one) ❑ New Construction ❑ Upgrade lA Repair
2. Published Soil Survey Available? LI Yes ❑ No If yes: -- --- ----- - - - Unft
Year Published Publication Scale Soil Map ap 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
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 Name - - ----
Wetlands Conservancy Program Map Map Unit Name
6. Current Water Resource Conditions (USGS): Month/Year Range: ❑ Above Normal ❑ Normal ❑ Below Normal
7. Other references reviewed:
DEP form 11 •rev. 1/10 Fonn 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8
Commonwealth of Massachusetts
a) qE City/Town of
l.r Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of two1 holes required at every proposed primary and reserved disposal area)
Deep Observation Hole Number: ` - ---- to Li it)
__ -- _.___-- --
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 feet Drainage Way feet Possible Wet Area feet --
Property Line feet Drinking Water Well feat 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