256 Certificate of Compliance 2008 •
Commonwealth of Massachusetts
City/Town of
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
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This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Co struction of a new system ingssimaimisi
❑ pair or replacement of an existing system
Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
ant- pa GfA"�
DSCP Number DSCP atii e
DSCP,Number ! osed-
Fact
Designer Information:
Ta.wres Ctrl.
Name
Name of Company
Signature
Installer Informs r-•
N � / A bt A CIO0 ^
Da Signature Name of COmpa��/O�
Date
Date
Use of this system is conditioned on compliance with the provisions set forth below:
•
The issuance of this certificate shall not be construed as a guarantee that the system will function as
Certificate of Compliance•Page 1 of 1