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STATEMENT OF COMPLIANCE
TOWN OF
TH S L ' TER CEt TIriES-MAT Tl`il7 oNsj-r,=SEWA,G=038poSAL SYSTEM INSTALLED
AT
FOR: NEW CONSTRUCTION
EXISTING STRUCTURE
ON iD Z` (,ATE) 13y _x -e_k (INSTALLER)
FOR r"''� �3 t sir"� �•fi l�� �+ '� (t7b�lttEF;3
HAS BEEN CONSTRUCTED IN ACCOROANCE WiTH THE PROVISIONS OF T1TL.E 5.
SPECIAL PRONASIONS ARE AS FOLLOWS:
THE SIGNING OF YHIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE
THAT THE SYSTEM WILL FUNCTION AS DESIGNED.
THIS FORM IS NOT THE 'CERTIFICATE OF COMPLIANCE' ISSUED BY THE BOARD OF
HEALTH.
(DATE) {DESIGNER) ��n�
J_MUSTAIN, RS#1 133
Tel. 413-537-1214
No vd THE COM ONWEA TH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFI ATE OF CO PLIANCE
❑ U
Description of Work: Individual Component(s) Komplete System
The undersigned hereby certify that the Sewage Disposal System-,Constructed( ),Repaired ),Upgraded( ),Abandoned( )
by:
1 D
at
has been installed in accordance with the visions of 310 0 15.0 Title 5) an t e a d design plans/as-built
plans relating to application No.�d�'� dated Approved Design Flow design
Installer ! - -
Designer:
Inspector Date
The issuance of this certificate shall not be construed as a guarantee t the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
InT I-1�IN 1'-YI-I -f-' ?1�T[7