DATE: _________________ LOCATION OF PERK: ____________________________
PROPOSED USE OF PROPERTY: _________________________________________
OWNER OF PROPERTY: _______________________ Home Phone ______________
ADDRESS: __________________________________ Work ___________________
SIGNATURE AND LICENSE NO. OF SOIL EVALUATOR RESPONSIBLE FOR PERFORMING TEST :
Printed Name of Evaluator Signature of Evaluator Phone # of Evaluator
Engineer’s Printed Name ________________________Phone #_______________
DIG SAFE #__________________________________
TOP PORTION MUST BE COMPLETED OR WILL NOT BE ACCEPTED
Engineer must provide a scaled plan of the proposed area of the perc test.
It is the responsibility of the engineer to ensure that the proposed perc testing to be performed meets Title Five requirements. Any issues that may involve another Department must be addressed with that Department.
I____ _______________________Professional Engineer for the proposed percolation test noted above take responsibility to ensure that all requirements of Title V and Town By-Laws are adhered to. Furthermore I have been notified per this agreement that it is my responsibility to ensure that any/all departments of the Town are notified of this percolation test, if it appears to affect their Department.(Engineers Stamp here >)
The fee schedule is as follows; $60.00 per hour (with a minimum charge of $225.00)
For applications for septic repairs, (consisting of only 1 component)
$80.00 per hour, In excess of 2 hours for New Construction or upgrade, and systems with a design flow in excess of 2000 gallons per day.
Additional Fee’s are to be paid to the Health Agent by check at the site.
There will be a $25.00 fee for failure to notify of cancellation after the testing date has been set.