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HomeMy WebLinkAboutPercolation Test - Form 12 ..,.., Commonwealth of Massachusetts •sit.,...,, 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. Important:When A. Site Informatio)3, , filling out forms / on the computer. r V)i II p , ----1 14e. . .........._. ........ ... use only the taD key to move your Owner Name cursor-do not 7362 C,/,itow— s use the the return - StreetAddress pi.Lot# key. ,....5 0,4-rh eiothit) /1 2 4 0 d 6 6 91 1111 i pri , ------ . atoll' ' 4/ # Contact Person(if different from Owner) 1-elephoneAumber IM I B. Test Results 01 — 0`t/o/...1./ Day- Time Date Time Observation Hole# / c0 li Depth of Perc frel '7 6,givtg, 04. ...I Start Pre-Soak /Loo tietir' Ctvl ii,r _ • 4 tA i 6 End Pre-Soak ..--------- Time at 12" Time at 9 ( " Time at 6' - ... Time (9"-6") SS e2 rkAtts, 4, ,,,,,,,, Rate (Min./I ch)scej Test P ssed: Test Passed: Test Failed: E Test Failed: _ ___ ..._... C] C:1 z. l.... Test Performed By• V)/• Wille" air-1 ill ' XE - cl 5‘(a. . _. Board of Health Witness 1--e(4/(5 /VA- Comments: --- - , AS'S/ 4- iticarAi *ate 4,4•,(770,10.4-11-4 i ---- .. , t5form12.doc•08115 Perc Test•Page 1 of 1 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Philip / i c 6 e, Owner Name90 tji/1 0(,/ Street Addres Map/Lot / #,�-� 11O_...........__........................._..............................................._......_............._..........___._.....__....._...._ ___................_ 414c) 0 U an-(1. Rif- City State Zip Code B. Site Information 1. (Check one) 0 New Construction i Upgrade 2. Soil SurveyJD / $kra' 4S CCfr C k e—fr--" Source D(�w Soil Unit Soil Series _..44 itiol f A _ Landform Soil Limitations �_............_._.._ . �_..__.... 0(4 itt.v-r 1,1 Soil Parent material 3. Surficial Geological Report — Year Published/Source Map Unit Description of Geologic Map Unit: 4. Rood Rate Insurance Map Within a regulat y floodway? 0 Yes o 5. Within a velocity zone? 0 Yes No If 6. Within a Mapped Wetland Area? 0 Yes No yes, MassGIS Wetland Data La yer: Wetland T -- 7. Current Water Resource Conditions (USGS): Range: ❑ Above Normal orrrtal © Below Normal Month/Day/Year , 8. Other references reviewed: ir (Zone II,IWPA,Lone A,FEA Data Portal,etc.) /t'l 7( „.„„. . ...... t5forml l revised 1.23-20.doc Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 5 . . gil :it' 5'.4 N 0 .7' 0 iii ' 5i,.. 6-"N gzs Iii ca I 154. g 1 > o = ..... 0- i64.‘ tr. ..... 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CD Le's :Li"N, CA g 0 07) to o ....... WWI (.8 0 ta r•-. . c - -c 1 TA c Cl) 0 3 0 •-..,,. o ..q as 1.- CD ---: 0 r .....z ..„.co . 0 75- ca cr i 7..- o a.Zo's o -0 g....I a i 1 suas. ,..-. a) zo- w ct 6, —= 5' 0 a) 5nI ;.,....4: o O 0 Cn 00 L.) Er --ni 12 1 i CI) *: a. av " 0 cr., ra 5 n . u3 to x- 0 CD r -o to as 2 3- (1) 0 ••••.. 0. • . 0 -0 ...o (cs us I t•ss : o , s I . Commonwealth of Massachusetts '244r4 City/Town of s 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: Hole II Date Weather Latitude Longitude Longitude 1. Land Use: (e,g..woodland,agricultural field,vacant lot,etc,) V elation Surface Stones g.,cobbles,stones,boulders,etc,) Slope(%) Description of Location: 2. Soil Parent Material: Landfarm 'osition on Landsca SU.SH7BS, FS,TS,Plain) 3. Distances from: Open Water Body et Drainage Way feet Wetlands feet Property Line tee: • inking Water Wel feet Other feet 4. Unsuitable Materials Present: D Yes D No I Yes 1:1 Distur ted oil/Fill Material 0 Weathered/Fractur d R -k U .rock 5. Groundwater Observed:CI Yes 0 No If yes: Depth to Weeping in Holt I Depth Standing Water in Hole Soil L• Coarse/Fragments s \ Soil Soil Horizon Soil Texture Soil Matrix:Color- Redoximorphic Featur %b Volu Soil Depth(in) Consistence Other /Layer (USDA) Moist(Munsell) bles& Structure Depth Color Percent Gravel (Moist) Stones : Dpi. Coo Coo : Dpi: Cnc Dpi Coo Dpl Cnc : Dpi Additional Notes: t5torrei 1 revised 1-23-20.doc Form 11 —Sod Suitability Assessment for On-Site Sewage Disposal Page 3 of 5 e, Commonwealth of Massachusetts ` 7City/Town of r ;. Z . Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used (Choose one): Obs. Hole# I Obs. Hole# ❑ D to soil redoximorphic features / inches t� inches Depth to observed standing water in observation hole ( � I inches inches ❑ Depth to adjusted seasonal high groundwater (Sn) inches inches (USGS mgj� dd.•� r2pA /t/f/CY fr/' J�'�jf C.:" Index W Numbe' Readinte Sh= Sc—[Sr X (OWe—OWrnax)/OWr] Obs. Hole/Well# Sr; Sr OW. OWr-,3x OW Sn E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does a ast four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes ❑ No (/ /� r b. If yes, at what depth was it observed (exclude 0,A,and E Horizons). Upper boundary: d 1 Lower boundary: r ,.♦/ inches c. If no, at what depth was impervious material observed? 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