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/ // //
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APPLICATION MUST BE SUBMITTED 10 BUSINESS DAYS PRI9R T• THE SCHED LING OF A PERC TEST
Application for Percolation ("Pere") Test
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>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