25 COC 2023DocuSign Enve:ape 1D: FB6495FC-2E8140B6-8E11-7371003C5%F
Commonwealth of Massachusetts
Offi5moz City/Town of
gm_4 9 -
Certificate of Compliance
7 Form 3
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t5form3.doc- 06103
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
❑Q 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):
2023-115
918123
DSCP Number
DSCP Date
Allison Ryan
Facility Owner
25 Birch Lane
Street Address or Lot #
Northampton
4'f�;
MA 01060
Zip Code
Cityrrown
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State
Designer Information4/
Michael Pietras
'
.-
Engineering & Land Solutions Inc
Name
1 ;`
A ;
Name of Company
A'1
Signature
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Date
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Installer Information:
Randy Baker
u5 nM by:
et owe:ca
Baker Excavating & Construction Service
Name of Company
10/7/2023 1 5:48 PM EDT
Date
Use of this system is conditioned on compliance with the provisions set forth below'-
No
elow:No garbage disposal.
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Health Dept Agent
/fperpaoqjkathority 10/5/2023 1 7:23 AM EDT
Date
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Certificate of Compl.ance • Page 1 of 1