296 Certificate of Compliance 2004 FORM 3A - CERTIFICATE OF COMPLIANCE
Fee
No._
COMMONWEALTH OF MASSACHUSETTS
wr
Board of Health, Nai ..Q7as. , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) LN Complete System
The undersigned hereby certify that the Sewage Disposal System:
Constructed (0 Repaired O, Upgraded O, Abandoned ( )
by: IVG14er ) hnxee J<r EACavai*ny \4(Il3\2-4q— JS12
at: 2% S-yivesfer &Li (Lesko Rorrly j
has been installed in accordance with the provisions of 310/CMR 15.00 (Title 5) and the
approved design plans/as-built plans relating to application No.
dated -3-4.1y 7, 7oD3 Approved Design Flow 507 (gpd)
tAialtr.) a-1kt,
installer
Designer:
Date 5//7/0¢
Inspector
The issuance of Ihis permit shall not be c on,t rued as a guarani ce that the system will
function as designed.
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Sent By: Milltown Environmental Consulti; 413 247 5464; May-17-04 3:33PM; Page 212
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