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33 Septic Certificate of Compliance 2015 Important:When filling out fors on the computer, use only the tab key to move your cursor•do not use the return key 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. t5form3.tloc•06/03 This is to Certify that the following work on an On-Site Sewage Disposal System ❑ Construction of a new system ❑ jjeepair 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): 20 IS �� `(�L r2ot5� DSCP Number DSC6P ate f $Ird.". Lnr Facility CM os Street Address or Lot# ee 5I cQA&c-e /Mr �C City/Town Designer Information: Alan Weiss, RS Name/ t Signature Installer Information: KoYi 5 £n(co Name State ala6z Zip Code Cold Spring Environmental Consultants Inc! Name of mp i67y zwys- Date 1111te iikeoia:i5 Name of Company y/t/e/10 at Date Use of this system is conditioned on compliance with the provisions set forth below: f/vv0 5/(14' The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. 13E �Ata all FEEft A!•roving Authority S re //J Date Certificate of Compliance•Page 1 of I i 6--a--prnae-p Cv o y )-a-m'a'y' -z crite r' '�_'-'? O -�-Q a>z�r C-7-7 47�(/ � > /1Ar9 S, trine D'-T-p-c$ N� y"y- m „i tv• _ q nb ni ly--Y �y ? Z2 - 7�r 1 n %� 0,19 U 19- t Jf. S-s--0-(74/