Lot 6 Compliance Certificationn 2004 FORM 3A - CERTIFICATE OF COMPLIANCE
CERTIFICATE OF COMPLIANCE
Description of Work: _Individual Component(s) X Complete System
The undersigned hereby certify that the Sewage Disposal System:
Constructed X Repaired Upgraded_ Abandoned
by: Sam Browning
at: Lot# 6 - North Farms Road - Florence Massachusetts
*** This system has been installed in accordance with the provisions of 310 CMR
15.00(TitleS) and the approved design plan / as-built plans relating to the
application No
dated: September 28, 2004 Approved Design Flow: 21 Infiltrators
495 GPD
Installer: Sam Brow _ 1- r3: an•e Rd. - Northfield MA
.= rmow.--
Designe Inspector:
Timot
Date: November 6,
SANIT APB%
The issuance of this permit shall not be construed as a guarantee that the
system will function as designed.
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Existing well
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Existing
3 bedroo
house \
0 0 • 3 Infiltrator Trenches
4 t I Existing Septic Tank
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i 4Ito Distribution box ,, f
4" pvc solid pipe `� �,/4S
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A5-BUILT DIMENSIONS r
Distribution box
' ' to '6' = MG' / Distribution bo
'DD' to 'H' = 69' IP found J/ As-built plan
'E' to 'G' = 28' >4 3 Infiltrator Trenches
'E' to 'H' = 37'
7 Infiltrators / trench
'F' to '0' = 33' IP found Lot # 6 — North Farms Road
'F' to 'H = 315' Florence, Massachusetts
•
eett oillevracuporcw, W augeh Beet¢
212 Nan Street
72onel , 71244 01060
lee. 413-587-1214
lax 413-587-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE SYSTEM INSTALLER
INSTALLER SIGN-OFF
Thhiisi to certify thh(a�t the o ite wage dispos syste that I installed on � — LI— O l
-•�1 L (s2 /� !(Date) r
at the above-referenced address has been constructed in compliance with 310 CMR 15.00,and with the approved
plan and all local requirements.
.SAP+ 132w---■ ;,1qq 52 ra OR "' l:b Ivocinfh„o h..
(Pent Installer's name) J
(Address) a:>dc
Iz -a- O
(Date)
NOTE: This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal.