625 Certificate of Compliance 2018 Commonwealth of Massachusetts
C _� City/Town of f j3rh4 p-tP --
�=-jf- 1 Certificate of Compliance
a. .. 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
Important:When
filling out tons ❑ Construction of a new system
on the computer, ® Repair or replacement of an existing system
use only the tab ❑ Repair or replacement of an existing system component
key to move your
cursor-do not
use the return Has been doneinaccordance with Title 5 and the Disposal Syss'te Cons ruction Permit(DSCP):
key. D/C7 —/D .7 a ' ao/
DSCP Number' -+� (1� i DSCP Date
���_bbbb y Facility Owner jAo�tr, -4 1' MCe I M^y \
�°
X.
e,z6 We s4{, 1 , RI)
Street Address or Lot#
. 037...3 '..___ 0/04L.—.._.
City/Town State Zip Code
Designer Information:
Alan E Weiss, RS Cold Spring Environmental Consultants, Inc.
Name -- Name of Company
/� Signature Date G /`� �`�
r•-•
nil Insta er Information:
0eWI t.aC kWC7tUT— A ' - , 0 1
Nfrm
Name o Company
CZ re*•44.p,.A4/1.04,41../ 6 - I C_-LF'
Signature - -- Date --
INC Use of this system is conditioned on compliance with the provisions set forth below:
It is recommended that you pump tank every two years.
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
NORTIIAMPTfN, MA mnan
The issuance of this certificate shall not be construed as a guarantee that the system will function as
desi �n ye/( [,// //
d elsiprTN�4hr+rQ�fpN <.G 4 Air '-.
Approving Author' '/
_ aoc Signature / i Date
�,e /✓
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