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
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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):
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DSCP Number DSC6P ate
f $Ird.". Lnr
Facility CM
os
Street Address or Lot#
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/Mr
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City/Town
Designer Information:
Alan Weiss, RS
Name/ t
Signature
Installer Information:
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Name
State
ala6z
Zip Code
Cold Spring Environmental Consultants Inc!
Name of mp
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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:
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The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
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A!•roving Authority
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Date
Certificate of Compliance•Page 1 of I
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