43 Soil & Perc Tests 2011 r le
Commonwealth of Massachusetts
i City/Town of
Trim '
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued) f
Deep Observation Hole Number: - / Z_ A/// — S'"Sat..; -. . - -
Date Time Time Weather
1. Location
Ground Elevation at Surface of Hole: Location(identify on plan): --
2. Land Use /.... v"r - - ----
(e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%)
S
elation Landform Position on Landscape(attach sheet) tot/
3. Distances from: Open Water Body --`--- Drainage Way Possible Wet Area
-ZOO
feet feet feet
Property Line --- Drinking Water Well Other
feet feet 0 feet
4. Parent Material: �"'� y"' C -- - - Unsuitable Materials Present: ❑ Yes 0 No
If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Groundwater Observed: 0 Yes ❑ No If yes: Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater: — -----
inches elevation
tt r 'bs-1-4-d.,-• LI et
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:
A. B.
❑ Depth observed standing water in observation hole inches inches
A. _ B.
❑ Depth weeping from side of observation hole inches inches
A. B.
❑ Depth to soil redoximorphic features (mottles) - -
inches i nches
A. B.
❑ Groundwater adjustment(USGS methodology) in - --
inches 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: hes ---- Lower boundary:
inches
Commonwealth of Massachusetts
y1_
City/Town of
r 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
h
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.
Commonwealth of Massachusetts
1i ; City/Town of
— Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
I _ Y 9 p
E
Field Diagrams
Use this sheet for field diagrams:
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Commonwealth of Massachusetts
�
-a City/Town of
I 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
Consistence Other
Depth(in.) Layer Moist(MUnsell) (USDA) Cobbles& Structure (Moist)
Depth Color Percent Gravel Stones
Oir A loyr IA Wst_ tao,,.x4-#apse I
4i 11 9 " QW toyeT7 LS ' F.Se,,,,Jyt L-oose
/t ' Ct 2 .5y
5/3 zke" pc./ - VM. Se."-c3 t cm�.
a-st- 5 CZ . �
-dww 4-101“-L-4:--1 4',1
P,
At2. 4-22 " vtaI t07rs/! eler• t
a2-7 Et' i. s �I $73 s
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' 7 dditional r Notes:
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nportant:
Vhen filling out
rrms on the
omputer.use
my the tab key
r move your
ursor-do not
se the return
eY.
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 Informat/io�n . /
'C',/tj_C�i G.nlo r.//G?
Owner Name
f
0 Sits- ret.4vv lfi (a
City/Town
C ' O Q
State 5►ag
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)
7/777 [
Date Time ,Date Time
i a
43 " ,Beet. :r
i :sSr1
/ : so p
/ - 52len
PS5 pert
Test Passed: Test Passed: ❑
Test Failed: Test Failed: ❑
LA.)e-ts S
11 (cc en .441 t1 ^o n t / W/
0.Test Performed B
Witnessed By:
/ / // 4- pP/C As 74 4-2<cY
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