20 Perc Application & Test 2020,.a
City of Northampton Board of Health
212 Maln Street
Northampton, MA 01060
All -ss1-1214
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Fee Collected:
Perc Test Date:
A F'PI.,IC:AT'ION MUST BE SUBMITTED 10 BUSINESS DAYS PRIOR TO THE SCIHEDULING OF A PERC TEST
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Application for Percolation ("Pere") Test
Date of Application: z�tj X;;Eo, C?o
Address:
City1'T0wn/St2te/Zip Code:
CLICK LIST
New Construction
xRepair/Upgrade
""Number of Lots to be Pere Tested —New Construction only- Give Lot Numbers***
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Dig Safe Sign -Off: Gas/Electrical
Trench Permit/Info Sign Off from DPW 58!7 4570
for Soldo sjfl6 Vsc Only
CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
Public Health Director — Herridith O'Leary
Municipal Building — 212 Main Street — Northampton, MA 01060
Phone (413)587-1215 —Fax (413)587-1221
http://www.nort.hamptonma.gov/245/Health ` `2
Pere Test/Soil Evaluation
Property Address:
Owner's Name: _�;i'"t'��if'i�}kfi�'�tall{11M i7���(�i+Isi'>Nlii 3l s� {;k�S7Y'fti'7�Yiil€r
Date: ,.` tl ut trl;T
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Performed by:tp,I�
Witnessed by:
No. of Bedrooms:r'}�s,j
1,41h,,
Garbage Grinder? {i s N t
Fee Paid? Yes
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of deep holes/pere(s)
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