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Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
❑ Repair 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):
DSCP Number
Jeff& Susan Doyle
Facility Owner
933 Westhampton Road
Street Address or Lot#
Florence
City/Town
Designer Information:
James A. Gracia
e
DSCP Date
gnature
Installer Information.
John Tautznik
MA
State
James A. Gracia, PE
01062
Zip Code
Name of Co pany
3o)2as3
Date
Tautznik& Sons Excavating
Name of Company
S 30 -/3
Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not con trued a�guar�ee th�the syst m will function as
/rye l r0 • rc e 5.✓ //
Approving Authority
670? i3
desi
Signature Dat
m3 door 06/03 Certificate of Compliance•Page 1 of 1
ES A. GRACIA, PE
anda1e Street, Easthampton, MA 01027
NEW
20'x35'
EACH FIELD
ISPECTION PORT
EXISTING
1500 GALLON
SEPTIC TANK
JEFF & SUSAN DOYLE
933 WESTHAMPTON ROAD
FLORENCE, MA
SEPTIC SYSTEM "AS BUILT"
SCALE: 1" = 30' 5-30-2013