1175 On Site Review 1996 FORM 12-PERCOLATION TEST
Location Address or Lot No.
COMMONWEALTH OF MASSACHUSETTS
,Massachusetts
Percolation Test
Time
Observation Hole/
Depthol Pere
Start Pre-soak
L (.;
End Re-soak
r at 12-
T at 9-
Time at 6-
Time(9•-6.1
_
Rate Min./Inch
•Minimum of 1 predation teat most be performed in both the primary area AND
reserve area.
Site Passed L� Site Failed ❑ '
Performed fly: titit4r tY c
Witnessed By f 2 -
Comments:
017.4MCanrm.rarer .
0
ltbn Addressor Lot#
I ) I y +- -- y k-.� —2-2,it
Hole Number I I Date
~
(, y 1 I Time I ! S I Weather I _`.
.ocation(identify on site plan)
Sod Texture
USDA
Land Use
rg-
Slope(%) I _- 'I Surface Stones
Vegetation
C ,
Landform
3
on on Landscape(sketch on the back)
Distance from: ..
en Water Body
/p� ' ""- feet
Drinkinq Water Well
N/c feet
Property Line
-. feet
;sible Wet Area
— feet
Drainage Way
L -- feet
Other
feel
DEEP OBSERVATION HOLE LOG*
Hole#:
DEEP OBSERVATION HOLE LOG'
—•..•
minimum Ut inu MULts mtuudbDAL EVERT PROPOSED DISPOSAL AREA
h from
(Inches)
iN from
Intlnee
Soil Modica
Sod Texture
USDA
Soil Cdor _
Muree
Sod
Moo •
Other _
structure,Stones,Boulders.Consis> •%Ga .
1
C ,
I
3
l
1IMahNI .....Ic r-.Ih to Bedrock
0-•N b•mundwater. Stndi •Water in the HOk
Wee.' •from Pit Face Inallill
EsNnated Season al H'•h found Water
DEEP OBSERVATION HOLE LOG'
—•..•
minimum Ut inu MULts mtuudbDAL EVERT PROPOSED DISPOSAL AREA
h from
(Inches)
Sod Horizon
Sol Texture
(USDA)
Sod Cobr
(Mmsed)
Sod
Wang
Other
(swcure.Stones,Boulders.Consistency.%Gave
1
C ,
I
Ma (geologic) I J Deptlnb Bedrock
bah to groundwater Standing Wales in the Hole
/r!"- > I Weeping from Pd Face I
Estimated Seasonal High Ground Water
/
A�rrE
T7JS� r4 GER TLF: •thaAL�e
/tt'l5by� �'i
MMON!N!€ LTH OF MASSACHUSETTS
aw / - MASSACHUSETTS
Qlertifi ttte of Clmnplittnre /
,,,���----4e e g e D' posal System installed II r/epaire r aced V 'n
�� ��f y for installed /r 9v. �1 � � Q �
at - '"" h ewnstructed in
accor4ance with therprovi$Lyrla of Title 5 and the for Disposal System Construction Permit No. dated
17777 V Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall ntcb(�gL@sf
Certificate expires o r / ((it)
DATE
guarantee that sys em will fu as desi ed. This
,E-
▪ E Co
N sill;
-
C ttO P414.
u c agI
F o C b
3 rim permission is hereby gr§k99ted
'431t3ectestruct ( ) or repair( A)an
▪ mW m
77
Inspector
THECOM►1PNWEALTIH OF MASSACHUSETTS
!!x`..``1111767 ilk 77'"// f
MASSACHUSETTS FEE
spzi st e ions nrtfnn ennit
/r<(1 ( /
// 7.5
to l
On-site Sewage System located at
ld s described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
• tMtto comply with Title 5 and the following local provisions or special conditions.
o a ma->
Vr bnstructionrusf be comp fetertwithin two years of the date below.
DATE // Gi Approved by
FORM 1255 Fey.3/95 n M.SULKIN CO.•BOSTON.NA