235 Perc Application 2018 City of Northampton Board of Health
f 212 Main Street ;111
r �'�' Northampton, MA 01060
413-587-1214
Permit Number: /,�
Fee Collected: 31f 07(/[/7
Perc Test Date: 4pr, / �5) 14
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APPLICATION MUST BE SUBMITTED 10 BUSINESS/ DAYS PRIOR TO THE SCHEDULING OF A PERC TEST
Application for Percolation ("Pere") Test
Date of Application: " 3 —Z
Home Owner Name: 7o e �q.e.L�Pea
Address: )'35 Cops Meq 0I1,,„ pci
City/Town/State/Zip Code: A)Ok-1 lt4,yg 1742 /v/ i O /OGO
SOIL EVALUATOR LICENSE NUMBER:
R.S.❑ Engineer( 13:11 5 ; stunk
ADDRESS
S' DetaT Ad fie✓ eke Ile vKp b/aSV
PHONE
413 J Yq- /8o
E-MAIL
EXCAVATOR
(back-hoe operaWr) Cu. CJit i- CC
ADDRESS 5 Wei( 5pr ,4t7c-f;Y/J, �jfl d/C3r
PHONE t(lyj-7-97- I6Olj
CHECK LIST
❑ New Construction
C4 Repair/Upgrade
***Number of Lots to be Perc Tested—New Construction only- Give Lot Numbers***
Dig Safe Sign-Off: Gas/Electrical AI' S/5-o I1 q9
( Trench Permit/Info Sign Off from DPW(413) 587-1570
C) 8— 3c? `LIa3/1.2
For Board or Health Ilse Only
e� ' 41, l /tel ' @ 9441