34-023 (5) THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H LTH
t 4 , rdif irate of CInut�li itrr
tat the I v' ial Sewage Disposal System constructed rte-) or Repaired ( )
by- ................................ ........ .) ..........................................................
....................4�...-...._.. ... 1 taller
at............. ... ,
..... ...........'.................................•-•----•----............---•---•
has been installed in accordance with the pros si ns of TITLE ` of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....J��... .. ... ............ dated.........A)--..".R/.",r,....�......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE - AT THE
SYSTEM WILL FUNCTION S ATIS��T�R > J
DATE._...... I�'=•f i
Inspector............. .... ..