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20 Soil Suitability 5-2020Uorrifflonwealth cifassayhu; etts = ' S City/Town of &R ThMMF 0T J Form 1I ® Soil Suitability Assessment for ®n -Site Sewage Disposal A. Facility Information 2o ) - Omer Name —7� AA Tk4 d Street Address Map/Lot �� o # r 2 60~v T1.1Aoi/>TOW C.01060 ity State Zip Code s B. Site Information 1. (Check one) ❑ New Construction ❑ Upgrade Repair 2. Soil Survey Available? 9 Yes ❑ No If yes: Source Soil Map Unit Soil Name Soil Limitations Soli Parent material Landform 3. Surfciai Geological Report Available? ❑ Yes ❑ No If Yes: 19&9 A:� Year PublishedlSource Map Linn Description of Geologic Map Unit: 4. f=lood Rate Insurance Map Within a regulatory floodway? ❑ Yes No 5. Within a velocity zone? ❑- Yes �, No 8. Within a Mapped Wetland Area? H Yes No If yes, MassUIS Wetland Data Layer: Wetland Type 7. Current Water Resource Conditions (USGS): 5-12 C/ Z_& Range: ❑ Above Normal Normal ❑ Below Normal Month/payl Year 8. Other references reviewed: �y�c:.� �i /:jldL)`/�/2 G j s�,� �'f1�L u.,e" G / L UIe t5formI l.doc • rev, 5115/18 Form 11 — Soil Suitability Assessment for On -Site Sewage Disposal • Page 1 of 5 Commonwealth of Massachusetts x- City/Town of _ Form I1 - Soil Suitability Assessment for On -Site Sewage Disposal C. On-St"td Review (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: rp .5'&!'> 2 �1 - Hale # Date Time Weather Latitude 1. Land Use:5�/st✓ / 51�.Id!✓T/� Gc%lJU�r ;sc�- r"c (e.g., woodland,g�lt� field, vacant lot, etc.) Vegetation Surface Stones (e.g., cobbles, stones, boulders, etc.) fliDescription of Location: Longitude: �t Slope (%) 2. Soil Parent Material: e 4 '�4 e- '6- ir, 5 Landform Position on Landscape (SU, SH, BS, FS, TS) 3. Distances from: Open Water Body ��_//feet Drainage Way 1X''4eet Wetlands VI-eet Property Line _ f eel �" Drinking Water Well ZAP feet Other feet 4. Unsuitable f Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ] Bedrock -610� 5. Groundwater Observed EJ Yes ❑ No If yes: 7 7 Depth Weeping from Pit Depth Standing Water in Hole Soil Lo Depth (ln) Soil Horizon /Layer Soil Texture (USDA) Soil Aftatrix: Color-i{tlolst (Munsell) Redoximorphlc Features Coarse Fragments % by Volume Sail Soil Structure Consistence Depth Color Percent Gravel Cobbles & (Moist) Stones Other /n M 3/3 - r _ N JW f ig t6 r Gy'i f0 Additional Notes: a _. _ wf Deld c, _ —L/ N _ a7� �2 _ ' 401 t5forrnl 1 - rev. 3/15/18 Form 11 — Soil Suitability Assessment for On -Site Sewage Disposal • Page 3 of 5 Commonwealth of Massachusetts U City/Town of Forret 11 ® Soil Suitability Assessment for On -Site Sewage Disposal G. On -bite Review (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number:— zi 17- 7 %'0� Cl / e_., 1,7 n e_1— ,- _ Hole L GCG [i v H Date Time Weather _ Latitude �lt /.5 � �ce �tlooel_ longitude:, 1. [.and Use E.� 1'y %r_.e� %� J'-'�' cv �r�� �- /� / !�, ..., (e,g., woodland, agricultural field, vacant lot, eta,) Vegetation Surface Stones (e.g., cobbles, stones, boulders, etc.) §tope %) Description of Location: ! o /-1 x4IFS 2. Soil Parent Material: 3. Distances from: Open Water Body '�4feet Landform Position on Landscape (sU SH BS FS TS) Property Line 4. Unsuitable Materials Present: ❑ Yes ❑ No if -Yes: ❑ Disturbed Soi 5. Groundwater Observed: ❑ Yes [- No If yes: Drainage Way V yu%%et Wetlands feet Drinking Water Wel[ -' feet Other a feet I ❑ Fill Material ❑ Weathered/Fractured Rock Z8edrockc3 A.11&A.j i__ A104.,,,. Depth Weeping from Pit Depth Standing Water in Hole LIME". Depth (in) Soil Horizon Soil Texture Soil Matrix: Color- Redoximorphic Features Coarse Fragments /o by Volume Soil /Layer (USDA Moist(ANunsell) Soil structure Consi(Moisstence Consistence Other Depth Color Percent Cravat Cobbles& Stones 0-9 } /� �% t roup �% - ,�o�c- ,7,0,0E GleAA) Flt 14 i v res 14 oil M g y V1 S7, N,9,U6 Wo -'042 r-XIA $COcK'Y 0 11Z 61, rY SJ'/O No d lVvsog &A4 1A) Gov Sc- YCR6© sic Y 5fi�i� Additional Notes: !(JU rra;EFrrycb ��'_o Moirc AjG h>Y/c S t5forml l.doc • rev. 3/15118 Form 11 —Soil Suitability Assessment for On -Site Sewage Disposal • Page 2 of 5 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On -Site Sewage Disposal C. On -Site (Review (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: r._ / Sj 2 7 12 d /7; ja? 9,M c7U"1,4, � 'Yx er? vS Hole # Date Time Weather 11 Latitude 1. land UseC r9 A) 7' is tHiA)D 2-P5 F)et 0 AJ.E (e.g., woodland, agricultural field, vacant lot, etc.) Vegetation Surface Stones (e.g., cobbles, stones, boulders, etc.) Description of location: 0Ur f,4A,5 ' f .P!?RC� M vACI'40r- 09 2. Soil Parent Material 3. Distances from: Open Water Body Property Line 4. Unsuitable Materials Present: ❑ Yes © No Longitude: 3 X %r Slope (% .3.5fS Landform Position on Landscape (SU, SH, BS, FS, TS) �Zno feet Drainage Way 7ZOD feet Wetlands R guo feet feet Drinking Water Well '714d feet Other PIVA 'feet If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ® Yes ❑ NO If yes: 2f 4 Depth Weeping from Pit Depth Standing Water in Hole Soil Log Depth (in) Sail Horizon Soil Texture /Layer { Soil Matrix: Color- ftedoximorphic Features Moist {Munsell) Depth Color Percent Coarse Fragments /o o Soil b Volume Soils ructure Consistence Cobbles & Gravel Staves (Moist) Other(USDA �i A-p- `� sly - — _ - �J3o e1j'jL �a !o %R G/� 5 67a F"Er� M�Sr 3IV 061474Ya4v % -1(J IO Y2 SjS 5- v`"`?o Fn /RcS'G1C�f0TL.y 13t0c-may Additional Notes! 14 c�iry _ — _ i7r�rnlG_ t 'HWT 3 t3 t5forml I • rev. 3115/1 a Form 11 — Sol! Suitability Assessment for On -Site Sewage Disposal • Page 2 of 5 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for ®n -Site Sewage Disposal D. Determination of High Groundwater Elevation 9. Method Used: Obs. bole # %% / Obs. Hole* 1�- Z_ Ly' 'Depth observed standing water in observation hole SO inches 4 inches 0_15epth weeping from side of observation hole 9V inches inches Depth to soil redoximorphic features (mottles) V r. inches 1/9 inches ❑ Depth to adjusted seasonal high groundwater (Sh) inches inches (USGS methodology) Index Well Number Reading Date Sh = Sc — [Sr X (OW. — OWMax)IOWEj Obs, HolelWell## S, Sr OWr Ow"Z" OWr 2. Estimated Depth to High Groundwater: inches E. Depth of Pervious Material Sh I. 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? U' Yes ❑ No b. If yes, at what depth was it observed (exclude A and O Upper boundary: 6."6."9Lower boundary: �Cv" j,�6 Horizons)? inches inches c. If no, at what depth was impervious material observed? Upper boundary: Lower boundary: U �vv inches'?6 inches t5form11 - rev. 3115148 Form 11 — Soil Suitability Assessment for On -Site Sewage Disposal • Page 4 of 5 G �- • Comirr)onvvealth of Massachusetts qty/Town of - -�' Form 11 o 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. l further certify that the r;E= icated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.1 of Soil Evaluator Typed or Printed dame of Soil Evaluator / License # �, ld N, Zed a nz ra fj v C L' m Name of Approving Authority Witness Date — 4!:W3& 4 2 Expiration Date of License Approving Authority Noise: 1n 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 Fest Form 12. Field Diagrams: Use this area for field diagrams, tbformI I • rev. 3/15!18 A, ZC Form 11 – Soil Suitability Assessment for On -Site Sewage Disposal • Page 5 of 5 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of 1Vnq1_1,qt iPioA) Percolation Test Form 12 e 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 Infe�ma#ion lobe: -� 5 A lu Owner Name 20 i -f A�,) Nb 76M;vc Street Address or Lot # � b. �1"/�%1f CitylTown Contact Person (if different from Owner) B. Test Results State Zip Code Telephone Number .s/7-- -M 1 Date t5form12.doc• 08115 Perc Test • Pace 1 of 1 Time Dat` e Observation Hole # Depth of Perc Start Pre -Soak d2 s End Pre -Soak t P Time at 12" has Time at 9" Z Time at 6" t.._d QPM Time (9n-6") Z M r Rate (Min./inch) 0 M,O) 10 _ Test Passed: ® Test Passed: ❑ Test Failed: ElTest Failed:❑ Test Performed By:-.,.....�� 1 E av ' R _-_-- i e o L Z ft 3 0 Srf i G -J C Board of Health Witness _ Comments: t5form12.doc• 08115 Perc Test • Pace 1 of 1