MassachusettsDepartmentofEnvironmental.docVIP

Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Owner Name Street Address Map/Lot # City State Zip Code B. Site Information 1. (Check one) New Construction Upgrade Repair 2. Soil Survey Available? Yes No If yes: Source Soil Map Unit Soil Name Soil Limitations Geologic/Parent Material Landform 3. Surficial Geological Report Available? Yes No If yes: Year Published/Source Publication Scale Map Unit 4. Flood Rate I