6 WYMAN PLACE APPLICATION FOR DEEP HOLE OBSERVATION & PERC TEST 40 CITY OF SALEM, MASSACHUSETTS 10
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR Pro at
e.Protect.
TEL (978)741-1800
KIMBERLEY DRISCOLL health(@)sa1em.com
DAVID GREENBAI3M
MAYOR HF.AF"TH AGENT
APPLICATION TO SCHEDULE DEEP HOLE OBSERVATION & PERCOLATION TEST
Application to be completed by Soil Evaluator,Registered Sanitarian or Engineer
Address of property to be tested: 6 Wyman Place
Map#: 06 Lot#:3 Upgrade New Construction Yes
Upgrade with increase in flow N/A
Property Owner William Elliot Applicant(if different)
Owner Address 72A High Rock Street,Lynn Phone#781-589-3104
Applicant Address(if different) Phone#
Soil Evaluator Name Thad Berry Phone#987-500-8419 Is the Soil Evaluator a current
licensed Massachusetts State Soil Evaluator?Y/N
If yes,list license#SE 154 (If no,individual cannot perform soil evaluations)
Company Name ASB design group llc Distance to nearest wetland resource
area 150' Was a Notice of Intent Filed with
Conservation?Yes No X_
Has the parcel been tested before? If yes, date(s)of testing
Will the property be DIG SAFE certified before It esting . erformed?Y/N
Has a trench permit been filed with th ?�
enM ale i i testing?Y/N
Signature of owner or owner's agent
Print name A k-
Signature of applicant(if different)
Print name William Elliott
Fee: $180 per lot for upgrade or repair, $225 per lot for new construction
(Please make checks payable to the City of Salem)
Plot plan of property required with return application that shows presumed location(s)for testing.
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED
SOIL EVALUATOR MUST CALL FOR A TESTING DATE AFTER THE COMPLETED APPLICATION
AND..:.,...E.,...MUST HAVE BEEN�RECEIVED IN THE BOARD OF HEALTH OFFICE..,....a..�.,�..a..a....a.....tr.r...�.a..r.a.........■
FOR OFFICIAL USE ONLY
Date Received: r all `j Fee:' Received By: (L�tziody
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