505 Certificate of Compliance 2011 `T i<vr:d ci Heswk-1-t� Copy FORM 3A - CERTIFICATE OF COMPLIANCE •
No. Fee
COMMONWtEALTH OF MASSACHUSETTS
Board of Health, +n41,w„, 4Or_ , MA.
• CERTIFICATE OF COMPLIANCE
Description of Work: individual Component(s) ❑ Complete System
The undersigned hereby certify :hal He Sewage Disposal System;
Constructed ( Repaired ( ), Upgraded (Abandoned ( )
by: Clairy_c EX Coo/0AI vloi
at: 505 Nor+� Rrws5 RoUd
• has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and the
approved design plans/as-built plans relating to application No.
dated U / 10 is io /;. Approved Design FlowS?S (gpd)
Installer ri, i.,--? 6 '
Designer: , / Inspector
Date 23,/ /2-0I I ,
The issuance of this permit shall nal lie construed as a guarantee that the system will
function as designed.
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