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7 Perc Application 2017 City of Northampton Board of Health 2017 _ 212 Main Street I) ' • EI Northampton, MA 01060 413-587-1214 -• ,,�,= PERC TEST WITNESS FEE. S200.00 per 3 hours Permit Number: n $75.00 per hours after 3 hours Fee Collected: " 6� /7 _ _..�_.__.. itt4 w►- ' EFUNI)ABLE Perc Test Date: AY/ // // e JIPd W / Gt. APPLICATION MUST BE SUBMITTED 10 BUSINESS DAYS PRI9R T• THE SCHED LING OF A PERC TEST Application for Percolation ("Pere") Test v ,Gt OSS >ate of Application: -Tu 1= bI dome Owner Name: 1\C kt i_ L- TD C ART ►ddress: ri- S Cc_L>►v � 'ity/Town/State/Zip Code: 1\ o(Xt-k 1.T0 N i\-NA. O t O SOIL EVALUATOR LICENSE NUMBER: R.S.❑ Engineer A t . i S S ADDRESS 35- t-DMt- HONE / 3 - 39-3 5 g -C 9- boo f)-- -MAIL EXCAVATOR (back-hoe operatorl ADDRESS � N Ofd M !� >,-ll . S� � 0 � C. M P\ 0106Q. 'HONE z.113 ( Q (o -3 CHECK LIST ❑ New Construction epai pgrade ***Number of Lots to be Perc Testes — 'ew Construction only- Give Lot Numbers*** ❑ Dig Safe Sign-Off: Gas/Electrical nand ❑ Trench Permit/Info Sign Off from DPW (413) 587-1570G� U3' 21\I ❑ Conservation Commission/Planning Department Review Contact the Planning Department(413)587-1266 for the Conservation,Preservation&Historic Planner Prior to the Perc Test for review any possible conservation commission issues relating to Perc Test. 031 Conservation Sign-Off t.' For Board of Health Use Only