357 Septic Perc Test 2014 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.
"'°°"'nt when A. Site Information
filling out forms
on the computer
use only the tab
key to move your
cursor-do not
use the return
key
Owner Name
City/Town
Contact Person(i(different from Owner)
MA 01060
State zip Code
413:$204258
Telephone Number
B. Test Results
Observation Hole#
Depth of Perc
Start Pre-Soak
End Pre-Soak
Time at 12"
Time at 9"
Time at 6"
Time(9"-6')
Rate(Min./Inch)
itnessed By:
Comments:
tsfmml 2 doe.06/03
8.2$-14 8:30 AM.
Date Time Date Time
P1
3r bottom
8:46
9*1
9:01
9:24
10:08
42 minutes
144et per'ie it..'.
Test Passed: ® Test Passed: ❑
❑ Test Failed: ❑
Pero Test.Page 1 of t
Commonwealth of Massachusetts
City/Town of n
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information
tafartrfo
City
MA
Slate
Lot#
Z p Code
B. Site Information
1. (Check one) 0 New Construction
2. Soil Survey Available? ® Yes
Cheman-Hollis
Soil Name
3 Surficial Geological Report Available?0 Yes
is ii€
Geologic/Parent Matenal
4. Flood Rate Insurance Map
0 Upgrade
0 No
is No
Above the 500-year flood boundary? ® Yes 0 No
Within the 500-year flood boundary? 0 Yes
la Repair
If yes: Central Hargpah're
Soil omludons
If yes
Year Published/Source Publication Scale
it
Landtorm
7110
Soil Map Ural
Map Unit
Within the 100-year flood boundary? 0 Yes 0 No
® No Within a velocity zone?
Wetland Area'. Wetlands Conservancy Program Map
.O14_
MonthNear
6. Current Water Resource Conditions(USGS):
Other references reviewed
0 Yes 0 No
Map Unit Name
Range: 0 Above Normal 0 Normal 0 Below Normal
Deep Hole form•rev.3/13 Form 11-sou Suitability Assessment for On-Site Sewage Disposal Page 1 of e
Commonwealth of Massachusetts
City/Town of NQ '
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.
1. Location
Ground Elevation at Surface of Hole'. 50-4--- Location(identify on plan): Rea5oftot taffie HOFae.--
.al __.. . COMM/ 04%
re.,woodland.agricultural field,vacant lot etc.) Surface Stones Slope(%)
Milland upland__ ". .' _. _-----..
Vegetation Landmrm Poison on Landscape(attach sheet)
3. Distances from'. Open Water Body .40- Drainage Way — Possible Wet Area 50+
feet tee! feet
Property Line $q,}- - Drinking Water Well — Other
feet feet feet
4. Parent Material: ' ----- -- - Unsuitable Materials Present ® Yes ❑ No
DHt
p
DateDale
rme
e� aad�ta_
Weather
2. Land Use
If Yes'. ® Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) Q Weathered/Fractured Rock ® Bedrock
5. Groundwater Observed: g Yes ❑ No If yes:
Estimated Depth to High Groundwater: - "#.
Inches elevation
78'
Depth Weeping frorn Pit Depth Standing Water in Hole
Deep Hole form.rev.3/13 Form 11-Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of a
Commonwealth of Massachusetts
City/Town of NeirVenpton
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number:
BSI
Depth in.)
SoilLHaoynerxon/
Soil Moist
Redo x morphic Features
(mottles)
Soil Texture
(USDA)
Coarse Fragments
%by volume
so"
structure
Soil
Consistence
(Moist)
Other
Depth
Color
Percent
Gravel
Cthalea a
Moues
0
,,,
.«...:C ,*
'.F.
0
0
—
WOlitter
f0huniOs
24
A
61:
'
SandY
0
0
Saliak
Topsoil
IFS
Bw
7.6YR 4/6
Wel/
10%
0
Week
Friable
Subsoil
Of
$11*
7.6YR 5/
o
30%
20%
,
Fiat!
OStratum
39-96
CO
046tt4,4
it
S
aatYtd
$O%
10%
Moderae
Finn
StOtebetial
B
.
cat,
l'
i`
1
Ledge
aa
ww.
mitt
Additional Notes:
Deep Hole form•rev.3/13
Form 11-Soli Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8
Commonwealth of Massachusetts
City/Town of ai}tiyj-,ju,
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number:
1. Location
05-14 8:30
Date Time
Weather
Ground Elevation at Surface of Hole':
PAV
-- Location(identify on plan): ReaY fltl
Gal _-
(e.g..woodland.agricultural field vacant lot,etc.) Surface Stones
keeS _.. iWand G4aal Tel
2. Land Use
Orts
Slope(%)
Vegetation Landform Position on Landscape(attach sheet)
3 Distances from: Open Water Body 200+ Drainage Way 50± Possible Wet Area
feet feet feet
Property Line 20+ Drinking Water Well Other -"
feet feet feet
eti
4. Parent Material: Gl -770.-- -- -- - - - Unsuitable Materials Present: ® Yes ❑ No
If Yes: a Disturbed Soil Q Fill Matenal Q Impervious Layer(s) 0 Weathered/Fractured Rock M Bedrock
5. Groundwater Observed' ® Yes
Estimated Depth to High Groundwater:
❑ No
39
inches
If yes'.
95:3'
elevation
Depth Weeping from Pit Depth Standing Water in Hole
Deep Hole form•rev.3113 Permit-Soli suitability Assessment for On-Site Sewage Disposal Page 4 of e
Commonwealth of Massachusetts
City/Town of Pala*"
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number:
PEg
Depth(in)
Soil Horizon/
Layer
Soil Matrix:Color-
Moist(Monsen)
Recloximorphic Features
(mottles)
Soil Texture
(USDA)
Coarse Fragments
¶4 by Volume
I
Soil
_,
Stnn"nre
Soil
Consistence
(Moist)
Other
Depth
Color
Percent
Gravel
Cabbies S.
Stones
C
.T.
G 01
a 1
0
a
.
Leaf Liner
kdaiew4
A
Sandy
0
0
We*
, ‘
1319
, 7.6YR 4)6
°
.
. ..
0
Weal(
Ftiatde
Subsoil
M142
10%
**date
substratum
42-102
C2
51R414
04
.
it9ratlY
Li
10%
Moderate
102+
-
A•M
t• -
c
. .
I R
. '
Additional Notes:
Deep Hole form•rev 3/13
Form 11-Soil suitability Assessment for On-site Sewage Disposal •Page 5 of
Commonwealth of Massachusetts
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
® Depth weeping from side of observation hole
® Depth to soil redoximorphic features (mottles)
B Groundwater adjustment(USGS methodology)
Lam_
Index Well Number
Adjustment Factor
Inches inches
A.78 B.93
ch
inches inches g
A.h B.88
inches Inches
inches Incies
Reading Date Index Well Level
j3�sst4
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 13 No
b. If yes,at what depth was it observed? Upper boundary:
8
inches
Lower boundary:
Inches
Deep Hole form•rev.3/13 Form 11-Sol Suilability Assessment for OnSlle Sewage Disposal •Page 6 of a
Commonwealth of Massachusetts
City/Town of No '.ptp e
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.
nawm of Son Evaluator
Typed or Printed Name of Soil Evaluator I License
Editene
Date
&18/1995
Date of Son Evaluator Exam
HPalefeeparenent
Name of Board or 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 IZ.
Deep Hole form•rev.3/13
Form 11-Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of8
Commonwealth of Massachusetts
City/Town of
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
Field Diagrams
Use this sheet far field diagrams:
Deep Hole form rev.3113 Form 11-Soil suitability Assessment or On-Site Sewage Disposal •Page a of