5 WYMAN TERRACE PERC TEST RECEIVED
SEP 2 0 2022
6 CITY OF SALEM
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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: 5 �j I A,,, ( C--riz�.14. c
Map#:�Lot#:4-1 Upgrade_ New Construction
Upgrade with increase in fl
Property Owner�� ` ,y _ � plicant (if different)
Owner Address !c�1y' d, l Phone# � y 44
Applicant Address (if different) ` f 7;'hone#
Soil Evaluator Nanle\J,,.cl A r�T v_Ee,j Phone# 21)2 (0 3S �
Is the Soil Evaluator a current licensed Massachusetts State ';:oil Evaluator?(YY N
If yes, list license# S k (S 4� _ (If no, individual cannot perform soil evaluations)
Company Name Z, T,, LA r� > S rev G-, _ t.-.
Distance to nearest wetland resoi E c,___
Was a I\Tolice of intent Filed with C:oncervation?Yes No 4/
Has the parcel been tested before? ri L7 If yes, date(s) of testing
Will the property be DIG SAFE certified before soil testing is p rformed?(�/N
Has a trench permit been filed with the QiDy of Sale e soil to ing?A,."/N
Signature of ow,mu or owner's a$ejjt
Print name \J U-1 w--L2' .
Signature of applicant(if different)
Print name
Fee: $180 per lot for upgrade or repair, $225 per iot 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 FEE MUST HAVE BEEN RECEIVED IN THE BOARD OF HEALTH OFFICE
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FOR OFFICIAL USE ONLY
Date Received: _ Fee: 1 b_�' Received By: V is,