136 Perc 12-6-19 r; City of Northampton Board of Health
212 Main Street
Northampton, NU 01060
413-587-1214
Fee Collette :
Perc Test Da e: (3)1319 Q,.00 n6ov-i
APPLICATION MUST BE SUBMITTED 10 BUSINESS DAYS PRIOR TO THE SCHEDULING OF A PERC TEST
Application for Percolation ("Perc") Test
Date of Application:
gal 1
Home Owner Name: (LL
Address: I 3(e U 0\ �`( � ✓✓✓111
City/Town/State/Zip Code:
r
SOIL EVALUATOR. LICENSE NUMBER:
R.SX Engmeero r 1 3
ADDRESS f71 j y VV\AW I�-.FZ t- (Z 1'. `N tm TT I ,�C-C 0 49 M( - -
PHONE
Y( - .PHONE 1 L{Q 2
E-MAIL
EXCAVATOR
(back-hoe operator) vo S "
ADDRESS
3 S� G✓1/a-�-✓i �'M(.st-"� �t ten-U`n C.�' �M'�
PHONE 1 5 &o. S-18 (V (� a
PLEASE MAKE ALL CHECKS PAYABLE TO THE CITY OF NORTHAMPTON
CHECK LIST
❑ New Construction
❑ Repair/Upgrade
***Number of Lo s to be Perc Tested New Construction only- Give Lot Numbers***
❑ Dig Safe Sign-Off: Gas/Electrical
❑ rench Permit/Info Sign Off from DPW 4 58 5 t
------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------
For Hoard of Health Use Only
' CITY of NORTHAMPTON
P BI
C HEALTH DEPARTMENT %)Yv
Public Health Director—Merridith O'Leary
Muni ipal Building—212 Main Street—Northampton, MA 01060 f1
Phone (413)587-1215—Fax(413)587-1221 V
r http://www.northamptonma.gov/245/Health
(( Perc Test/Soil Evaluation Form
Property Address: O O
t
Owner's Name: TOAhl
Date: ja 11.31
Performed by:
Witnessed by: - fr vy/
No. of Bedrooms: ,, ," UJO �Q�td. � � 1�0 C
'A
LA
Garbage Grinder'!
Fee Paid? LI o Sketd�of pr6perty Location of deep holes/perc(s)
N
w Pe colation ' st
Perc Hole# 3 4
39
El v: '; lev `x. Elev: Elev:
Start pre-soak
End pre-soak
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Time @ 6"
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V-6„
Rate (min/in)
Q)11.1 4es +reAcjujn a Seca� Q on�� a D 's i Jed.
Deep Hole Observation Log
Depth From Soil Horizon Soil Texture Soil Color Mottling
Surface (inches) (inches)
SA Mq /oc,14 10 Yt rh
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?5,101 '�, 'Mr :»
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: CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
Public Health Director—Merridith O`Leary
µA Mu uicipal Building--212 Main Street—Northampton, MA 01060
Phone (413)587-1215—Fax(413)587-1221
http://www.northarimptonma.gov/245/Health
Perc Test/Soil Evaluation Form
Property Address:
s
Owner's Name: To a,n t
Date: 13
Performed by: Q; �
�� V ,.
Witnessed by:
t? K
No. of Bedrooms:
Garbage Grinder? ens pC1fl,�,5 F•C
,/
Pee Paid? �' Yes No Sketo of property�gn cation of deep holes/perc(s)
kpa
#Y a14
Pecolatian est ,
Perc Hole# 3 4
Elev: Elev: Elev:
Start pre-soak
End pre-soak
iS
iS ime @
a,uz..c ,,+3.z: `ms's`'..- '�` s �, • c:: 'a g � :., :.:, :�'$ - .�
Time @ 6'i
enk v r ga v ,. 6 :2qq n
9"-6"
Rate (min/in) LGi !�� '
Deep Hole Observation Log
Depth From Soil Horizon Soil Texture Soil Color Mottling
Surface (inches)
(inches)
san Aj,�rcLod L,
149-23 016 511suAd Lo v - Z I I noa-e-
-
23j0
0-10
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