139 Certificates G-5-1-2005 17:55 FROM:NORTHAMPTON BOARD OF 413 5871221
TO:914135291431 P.3
gat O !ione 4 tMOctr2, igstuadtadead
212Naas Street
'j2oatv'icuc ussrgoa, 214 01060
lee. 413-587-1214
lax 413-587-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE DESIGNING ENGINEER AND THE
SYSTEM INSTALLER
DESIGNER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Tine V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Installer and the Designer ofa system is
required to sign this form as a condition for issuance of a Board of Health Certificate of Compliance for the
onsite septic system.
This is to certify that the onsite sewage disposal system that f designed as: new construction
)( repair(existing system)
at 131 %" .77in y'AfoA/ .BPD on /-5-1.0,55- DWCP number 2/4-167
(Address) (Date)
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
- 3 Q93 9- 4RA62/9
(Print Design 's n
99 6L SNp te- S>� ESSMIH7as,70.J
(Address)
8 - 0s
(Design&'s signawre) (Date)
INSTALLER SIGN-OFF
This is to certify that the onsite sewage disposal system that I installed on 8- ✓`��S
(Date)
at the above-referenced address has been constructed in compliance with 310 CMR 15.00,and with the approved
plan and all local requirements.
ZS 64/...6-6.4-21/7/y 5dp7•Y9mp744.)
(Address)
Vse)r-
(Dam)
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable roles and regulations as are
in effect at the time of plan submittal.
MES A. GRACIA, PE
Glendale Street, Easthampton, MA 01027
NEW
PRESSURE DOSED-
LEACH FIELD
OLD LEACH PT
PUMPED OUT,
CRUSHED, AND
FILLED
NEW PVC
FORCED
MAIN
EXISTING
PUMP CHAMBER
EXCAVATED AND
SEALED FROM
OUTSIDE
Fl
of
u
,FIFO)
10 �r
•
•
•
•
•
•
•
• 30'
•
•
70'
EXISTING
3 BEDROOM
DWELLING
EXISTING
SEPTIC TANK
EXISTING
WATER LINE
s
I
3
73'
GAR.
—1
1 I
I I
i ROOF DRAIN
OUTLETS
I �
i
1 �
/
I
I I
I I
I I
1 I
I 1
1 I
WESTHAMPTON ROAD - ROUTE 66
ERIC & TRACY INDYK
139 WESTHAMPTON ROAD
NORTHAMPTON, MA
SEPTIC SYSTEM "AS BUILT"
SCALE: 1 " = 30' 8-12-05
' 212 71604 Street
72ortliauryitacs, 7114 01060
%Z. 413-557-1214
lax 413-517-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE DESIGNING ENGINEER AND THE
SYSTEM INSTALLER
DESIGNER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage, Section 15.021 (3),the Designer and the Installer of a system are
required to sign this form as a condition for issuance of a Board of Health Certificate of Compliance for the
onsite septic system.
This is to certify that the onsite sewage disposal system that I desinned as: new construction
,,,�,�� repair(existing system)
at (GI C(1— ii.C1LLD w,,ppwwsy on �Vuy 7, Zoo ,DWCP number
(Address) (Date)
has been constructed in compliance with 310 C?vIR 15.00, and all local requirements.Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
Ilan O'ihv/ G, onr,6.110 lls
(Pn t Designer' name)
's sigma
Designer's
-70 Map&&. RP - u esTnnmp /mn
(Address)
\A-RR(ij ' 7 00 7
(Dale)
INSTALLER SIGN-OFF
This is to certify that the onsite sewage disposal system that I installed on
3 - lS - 0-7
(Date)
at the above-referenced address has been constructed in compliance with 310 CMR 15.00, and with the approved
plan and all local requirements.
wafer R. `Ten y�T
(Print a ) &LI 1<rinC-1--ess146JCH2(
%a - 07
(Instal er sl_ ature)
(Date)
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal.