560 Certificates 2013 Commonwealth of Massachusetts
iCity/Town of Northampton
Certificate of Compliance
Form 3
copy
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
This is to Certify that the following work on an On-Site Sewage Disposal System
Cant:When
out farms ❑ Construction of a new system
computer, ® Repair or replacement of an existing system
illy the tab ❑ Repair or replacement of an existing system component
move your
le return Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP)1 le do not
2 DSCP Num r DSCP Date
AFacility Owner S
Street Address o
City/Town State r Lot —
1 wJ . _ .._ __. Zip Code
Designer Information:
Neme tea h __Ll
Sgnature
Installer Information:
Name
Signature
Use of this system is conditioned on compliance with the provisions set forth below:
_AlaMOo,
Name of Company
Date
Name of Company
Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed. sake I l ti 5r1to`` -t'f11�G,m Plc. ft11,
Approving Authority I_ Ian t.3
Signature Date
r� _ _112131190‘S
..123 —_—.
{ ft i� !1 ITV II
5form3.doc•06/03
Certificate of Compliance•Page 1 of 1
Inspection ports ("F"&"G")
11 50ft.
'Oft.
/--Existing distribution box ("E")
Existing 1,500 gallon septic tank
Cat]101Eds6€1111•111101,
201f ± of 4" pvc sol
mpout man—hole "0"
�21.SIf + of 4" pvc solid
e(5=.01)
pipe
4 bedroom
house
=75ft:
Existing well
Overhead utilities
® SYLVESTER ROAD — FLORENCE, MASSACHUSETTS
AS-BUILT DIMENSIONS
AS—BUILT PLAN
SUBSURFACE SEWAGE DISPOSAL SYSTEM REPAIR
HIGH CAPACITY INFILTRATOR TRENCH SYSTEM
2 Trenches with 10 Infiltrators per Trench
'54L —26051,Nester Road
Northampton, Massachusetts
January 22, 2013
"C" to "F" = 32.-0"
"C° to "C,• = 24'-4'
"B" to "F" = 45.
"B" to "G" = 41
-4•
—0"
AS—BUILT PLAN
SUBSURFACE SEWAGE DISPOSAL SYSTEM REPAIR
HIGH CAPACITY INFILTRATOR TRENCH SYSTEM
2 Trenches with 10 Infiltrators per Trench
'54L —26051,Nester Road
Northampton, Massachusetts
January 22, 2013
212 71144r Street
Woletcznrfitoa, 7114 01060
7e€. 413-587-1214
lax 413-587-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE SYSTEM DESIGNER
DESIGNER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Designer of a system is required to sign
this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic
system.
This is to certify that the onsite sewage disposal system that 1 desivned as: new construction
Replace existing sewage disposal system X Repair
560
at .26 Sylvester Road
(Address)
on January 22, 2013
(Date)
D W CP number
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
Timothy E. Maginnis R.S.
(Print Designer's name)
70 Montague Rd. —Westhampton, MA.
(Address)
January 22, 2013
(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 time of plan submittal.