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16 WYMAN STREET vAre4, sCe � J Griffin Engineering Group,LLC February 19, 2013 Mr. Larry Ramdin, RS/RENS, CHO, CP-FS Health Agent City of Salem Health Department 120 Washington Street, 4th Floor Salem, MA 01970 Subject: Proposed Septic System 16 Wyman Street, Salem, MA (Parcel ID: 02-0026) Dear Mr. Ramdin: On behalf of the Owner and Applicant, Bill Elliott, we are pleased to provide this submittal for the installation of a septic system for new construction at the subject location. The submittal includes: • One set of plans (Sheets C-1, C-2 & C-3); • Disposal Work Construction Permit Application Form; • DEP Soil Suitability Forms 11 & 12; • $225 filing fee. The project involves the installation of a 1,500 gallon septic tank, a 6-outlet distribution box, three bedroom soil absorption system (SAS) consisting of three trenches, 3.5-ft maximum high boulder retaining wall with impervious barrier, and 6.5-ft maximum high concrete retaining wall with impervious barrier. Should you have any questions or require additional information, please do not hesitate to contact the undersigned. Very truly yours, Griffjn�eerin Group, LLC Robert H. Gri m, P.E. Enclosure: As Noted Cc: B. Elliott Phone 978-927-5111 Fax 978-927-5103 www.griffineng.com amanI wdomwimm i maim sm I mr SL\ Commonwealth of Massachusetts City/Town of Salem r Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Riverside Realty Trust Owner Name 16 Wyman Street 02/0026 Street Address Map/Lot# Salem MA 01970 City State Zip Code B. Site Information 1. (Check one) ® New Construction ❑ Upgrade ❑ Repair 2. Published Soil SurveyAvailable? 1984 1:15,840 102C/102E ® Yes ❑ No If yes: Year Published Publication Scale Soil Map Unit Chatfield-Hollis-Rock Bedrock, High Groundwater Soil Name Soil Limitations 3. Surficial Geological Report Available? ❑ Yes ® No If yes: Year Published Publication Scale Map Unit Glacial Till Drumlin Geologic Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ® No Within the 500-year flood boundary? ❑ Yes ® No Within a velocity zone? ❑ Yes ® No 5. Wetland Area: National Wetland Inventory Map None Upland Map Unit Name None Wetlands Conservancy Program Map. Map unit Named 6. Current Water Resource Conditions (USGS): Aug/2012 Month/Year Range: ElAbove Normal ® Normal [:] Below Normal 7. Other references reviewed: t5form11-2010-rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal k WWI C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: TP-1 8/8/12 12:40 PM Sunny, 85 Date Time Weather 1. Location Ground Elevation at Surface of Hole: Location (identify on plan): 2. Land Use Woodland Exposed Rock Outcrops 3 (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Mature Trees Hills Summit Vegetation Landform Position on Landscape (attach sheet) 3. Distances from: Open Water Body >100 Drainage Way >100 Possible Wet Area >100' feet feet feet Property Line fee_t Drinking Water Well feet feet Other feet 4. Parent Material: Glacial Till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ® Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 32 inches elevation it t5form11-2010•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 �Lx Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: TP-1 Redoximorphic Features Coarse Fragments Depth(in.) Soil Horizon/Soil Matrix:Color- (mottles) %b Volume Soil Soil Texture y Soil Consistence Other Layer Moist(Munsell) (USDA) Cobbles& Structure Depth Color Percent Gravel (Moist) Stones 1-0 Oi --_- -__- _--_ ---- ---- ---_ ---_ 0-10 A 10YR 2/2 ---- ---- ---- SL >2% >2% Granular Loose 10-24 Bw 7.5YR 5/6 ---- ---- ---- SL >2% >2% Massive Friable 24-32 BC 10YR 6/6 32 5YR 5/8 60% FSL >2% >2% Massive Friable 32-48 C1 10YR 7/1 LFS 10% 5% Massive Friable 48-66 C2 2.5Y 5/4 LS 15% 5% Single Firm-in- Grain Place Additional Notes: NoNo wc�� ; lyi 1Uoavc- t5forml 1-2010•rev. 1110 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 �CN Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: TP-2 8/8/12 1:00 PM Sunny, 85 Date Time Weather 1. Location Ground Elevation at Surface of Hole: Location (identify on plan): 2. Land Use Woodland Exposed Rock Outcrops 3% (e.g.,woodland, agricultural field,vacant lot,etc.) Surface Stones Slope Mature Trees Hills Summit Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body >100' Drainage Way >100' Possible Wet Area >100' feet feet feet Property Line feeDt Drinking Water Well >10Other feet 4. Parent Material: Glacial Till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ® Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 25 inches elevation t5formll-2010-rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 Commonwealth of Massachusetts City/Town of Salem UnForm 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: TP-1 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix: Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel Cobbles& (Moist) Stones 2-0 Oi ---- ---- ---- ---- --- ---- ---- ---- ---- 0-6 A 10YR 2/2 ---- ---- ---- SL >2% >2% Granular Loose 6-16 BW 7.5YR 5/6 --- ---- ---- SL >2% 2% Massive Friable 16-64 C1 10YR 7/1 25 5YR 5/8 60% LFS 15% 10% Massive Friable Additional Notes: \ t5forml1-2010•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 <Lx Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal WWI D. Determination of High Groundwater Elevation 1. Method Used: Elin in Depth observed standing water in observation hole inches inches ElDepthin Depth weeping from side of observation hole inches inches A.® Depth to soil redoximorphic features (mottles) incheess in(TP-1) 25" (TP-2) nnches 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: in10 ches Lower boundary; 66hes t5form11-2010-rev. 1110 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal -Page 6 of 8 Commonwealth of Massachusetts City/Town of Salem 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 s� accqqurat��e and in accordance with 310 CMR 15.100 through 15.107. �� (ui}"c,.,�I Zs,� 8/8/2012 Signature of Soil Evalua r Date Michael Paige (13167) June 2009 Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam Larry Ramdin RS/REHS, CHO, CP-FS Salem Name of Board of 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 12. t5formll-2010•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8 �LN Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Field Diagrams Use this sheet for field diagrams: t5formll-2010•rev, 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8 Commonwealth of Massachusetts City/Town of Salem Percolation Test Form 12 w„ Percolation test results must be submitted with-the 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 filling out forms A. Site Information on the computer, use only the tab Riverside Realty Trust key to move your Owner Name cursor-do not 16 Wyman Street use the return Street Address or Lot# key. Salem MA 01970 r� City/town State Zip Code George Fallon 978-375-6150 Contact Person(if different from Owner) Telephone Number B. Test Results 8/8/12 2:48 PM 8/8/12 3:22 PM Date Time Date Time Observation Hole# TP-1 (Perc1) TP-2 (Perc2) Depth of Perc 38" 30" Start Pre-Soak 2:48 PM 3:22 PM End Pre-Soak 3:03 PM 3:37 PM Time at 12" 3:03 PM 3:37 PM Time at 9" 3:29 PM 3:41 PM Time at 6" 4:04 PM 3:46 PM Time (9"-6") 35 minutes 5 Minutes Rate (Min./Inch) 11.7 mpi 1.7 mpi Test Passed: ® Test Passed: Test Failed: ❑ Test Failed: ❑ Michael Paige Test Performed By: Larry Ramdin Witnessed By: Comments: t5form12.doc•06/03 Perc Test•Page 1 of 1 No. FEE 2ZS COMMONWEALTH Of MASSACHUSETTS Board of Health, SQ�em , MA. APPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT Application for a Permit to ConstructOO Repair( ) Upgrade( ) Abandon( ) - O Complete System ❑Individual Components Location :gcnortOwner's Name bM Ewo. Map/Parcel# 0a, _ CO3R Address Lot# Telephone# Installer's Name Tb Designer's Name o G,4-,- Address r, ,- Address Address r Obox 70 Co 1 Telephone# Telephone# 7 - S Type of Building 41nh1t F[wi A,. IV s, ,(� Lot Size 1 a, q-75 sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons — Showers ( ),Cafeteria( ) Other Fixtures Design Flow (min.required) 3130 gpd Calculated design flow 33U Design flow provided gpd Plan: Date a J 19 115Number of sheets 3 Revision Date Title 4Jepy" SvS`` Ct-., C',ke 310^ Description of Soil(s) S�j J Soil Evaluator Form No. Name of Soil Evaluator 1A,L� Date of Evaluation Pw/l 2 DESCRIPTION OF REPAIRS OR ALTERATIONS N2uf Sv$ ,: i,St� �ul�on S"A-1, & oj�u L4-60A , t ryn%4e4 a� 3 � cncLaS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections ............,.........................:,.,..,.................................,..,.....,....•..,..,,.......,.........•............. No. COMMONWEALTH OF MASSACHUSETTS FEE Board of Health, ,MA. CERTIFICATE Of COMPLIANCE Description of Work: Ll Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned by: at has been installed in accordance with the provisions of 810 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. , dated Approved Design Flow (gpd) Installer Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. ................................................... ...................,......,.............,,...•.....,...............,,.......;,.. No. FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, ,MA. MSF®SAI. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5196 A.M.sNkfn co.chedeOwn,MA Date Board of Health ,2� No. .,,. FEE d COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(X) Repair( Upgrade( Abandon( - O Complete System Q Individual Components - Location C Owner's Name . Map/Parcel# ^ t Address Lot# ._ Telephone# <- Installer's Name R Designer's Name Address - - - .. • ... Address - ` .-'-- -- Telephone# Telephone# �v n ✓ Type of Building C r 1 7 _ 1 Lot Size is—,5 sq.ft. Dwelling-No.of Bedrooms 2 Garbage grinder ( ) Other-Type of Building No.of persons _ Showers ( ),Cafeteria( ) Other Fixtures Design Flow (min.required) J j� gpd Calculated design flow j Jv Design flow provided J=�gpd Plan: Date ., Number of sheets Revision Date Tide Description of Soil(s) WW'"1 / L Wv.� J Soil Evaluator Form No. Name of Soil Evaluatory .\ 1 Date of Evaluation 6-7/ _ V DESCRIPTION OF REPAIRS OR ALTERATIONS \ i t The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date n Inspections. No. COMMONWEALTH Of MASSACHUSETTS FEE Board of Health, , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 For,5/96 A.M.Sulkio Co.chadeslwm,MA Date Board of Health Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Riverside Realty Trust Owner Name 16 Wyman Street 02/0026 Street Address - Map/Lot# Salem MA 01970 City State Zip Code B. Site Information 1. (Check one) ® New Construction ❑ Upgrade ❑ Repair 2. Published Soil Survey Available? ® Yes ❑ No If yes: Year 1:15,840 Soil Map 2E Year Published Publication Scale Soil Map Unit Chatfield-Hollis-Rock Bedrock, High Groundwater Soil Name Soil Limitations 3. Surficial Geological Report Available? ❑ Yes ® No If yes: Year Published Publication Scale Map Unit Glacial Till Drumlin Geologic Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ® No Within the 500-year flood boundary? ❑ Yes ® No Within a velocity zone? ❑ Yes ® No 5. Wetland Area: National Wetland Inventory Map None Upland Map Unit Name Wetlands Conservancy Program Map. None Upland MapUnit Name 6. Current Water Resource Conditions (USGS): Aug/2012 Month/Year Range: [:1Above Normal ® Normal E) Below Normal 7. Other references reviewed: t5fonn 11-2010-rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 Commonwealth of Massachusetts CityiTown of Salem 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: TP-1 8/8/12 12:40 PM Sunny, 85 Date Time Weather 1. Location Ground Elevation at Surface of Hole: Location (identify on plan): 2. Land Use Woodland Exposed Rock Outcrops 3 (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Mature Trees Hills Summit Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body >100' Drainage Way >100 Possible Wet Area >100' feet feet feet Property Line feet Drinking Water Well >1fee0D Other feet 4. Parent Material: Glacial Till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ® Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 32 inches elevation t5forml 1-2010-rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: TP-1 Redoximorphic Features Coarse Fragments Depth in. Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soll P ( ) Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel Cobbles& (Moist) Stones 1-0 Oi ---- — — --- ---- --- ---- --- 0-10 A 10YR 2/2 — --- --- SL >2% >2% Granular Loose 10-24 Bw 7.5YR 5/6 ---- ---- -- SL >2% >2% Massive Friable 24-32 BC 10YR 6/6 32 5YR 5/8 60% FSL >2% >2% Massive Friable 32-48 C1 10YR 7/1 LFS 10% 5% Massive Friable 48-66 C2 2.5Y 5/4 LS 15% 5% Single Firm-in- Grain Place ` Additional Notes: y a �rkio5 p i� t5form11-2010•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/Town of Salem ° Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal LOW C. On-Site Review (continued) Deep Observation Hole Number: TP-2 8/8/12 1:00 PM Sunny, 85 Date Time Weather 1. Location Ground Elevation at Surface of Hole: Location (identify on plan): 2. Land Use Woodland Exposed Rock Outcrops 3% (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Mature Trees Hills Summit Vegetation Landform - Position on Landscape(attach sheet) 3. Distances from: Open Water Body >100' >100' >100' feet Drainage Way feet Possible Wet Area feet Property Line f et Drinking Water Well >100' Other feet feet 4. Parent Material: Glacial Till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ® Weathered/Fractured Rock El Bedrock 5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 25 inches elevation t5forml1-2010•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 Commonwealth of Massachusetts City/Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: TP-1 Redoximorphic Features Coarse Fragments Depth(in.) Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel obblto a (Moist) Stones 2-0 Oi ---- ---- ---- --- ---- — ---- ---- 0-6 A 10YR 2/2 — -- SL >2% >2% Granular Loose 6-16 Bw 7.5YR 5/6 ---- --- ---- SL >2% 2% Massive Friable 16-64 C1 10YR 7/1 25 5YR.5/8 60% LFS 15% 10% Massive Friable Additional Notes: � �\e.Y'S �is 1w�•�\ t5fonnl 1-2010•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City[Town of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: B. ElDepthin Depth observed standing water in observation hole inches inches B. ElDepthin Depth weeping from side of observation hole inches inches A.® Depth to soil redoximorphic features (mottles) incheess incheess(TP-1) (TP-2) nn ❑ Groundwater adjustment(USGS methodology) A. B. 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: hones Lower boundary: 66nes t5fonn 11-2010•rev. 1/10 Form i t—Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 EN- Commonwealth of Massachusetts Cityrrown of Salem 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. 1 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. rLcr/ % P4„ 8/8/2012 Signature of Soil EvaluaO Date Michael Paige (13167) June 2009 Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam Larry Ramdin RS/REHS, CHO, CP-FS Salem Name of Board of 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 12. t5forml1-2010•rev. 1110 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal -Page 7 of 8 Commonwealth of Massachusetts CitylTown of Salem Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Field Diagrams Use this sheet for field diagrams: I t5form11-2010•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8 Commonwealth of Massachusetts City/Town of Salem Percolation Test Form 12 Yt 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. Imoutf:When A. Site Information fillingngout forms on the computer, use only the tab Riverside Realty Trust key to move your Owner Name cursor-do not 16 Wyman Street use the return Street Address or Lot# key. Salem MA 0 � City/Town State Zipp Code George Fallon 978-375-6150 Contact Person(if different from Owner) Telephone Number B. Test Results 8/8/12 2:48 PM 8/8/12 3:22 PM Date Time Date Time Observation Hole# TP-1 (Perc1) TP-2(Perc2) Depth of Perc 38" 30" Start Presoak 2:48 PM 3:22 PM End Pre-Soak 3:03 PM 3:37 PM Time at 12" 3:03 PM 3:37 PM Time at 9" 3:29 PM 3:41 PM Time at 6" 4:04 PM 3:46 PM Time(9"-6") 35 minutes 5 Minutes Rate(Min./Inch) 11.7 mpi 1.7 mpi Test Passed: ® Test Passed: Test Failed: ❑ Test Failed: ❑ Michael Paige Test Performed By: Larry Ramdin Witnessed By: Comments: t5forn12.doc•06/03 Perc Test•Page 1 of 1 / y / M / I R. NF N eituoc, tiGq • TP_, y �Iv u TP-2 r 1- Perc2 e16 VNMAN Parcel ID 02-0026 0 286 ac'r 5 �� • t NO, wYM �\ INTO, Y Ro • `SAP u•k f Y / - _. of Cj N • y \ tl�o�, h Mj�Altilq c - i ,�;i�!' � I✓ 11.. .^ - / .D.H. D.H S.cale: • Feet 16 Wyman Street Salem, - Griffin Engineering Group, LLC Soil Testing Plan Massachusetts 978-927-5111 D.