HomeMy WebLinkAboutEngineer Certification and As-Built Plan � Commonwealth of Massachusetts i -' - `
City/Town of Yu�rl'1�U l"� ,;i:i '► 0 2013 I
- .°� Certificate of Compliance j HEALTH DEPT.
> 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 CertiTy that the following work on an On-Site Sewage Disposal System
Important:
VJhen filling out ❑ onstruction of a new system
forms on me �Repair or replacement of an existing system
compucer,use � Repair or replacement of an existing system component
only the tab key .
to move your � �
cursor-do no� Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
use the reWrn
key.
� DSCP Number OSCP Date
��x r�;�� T�us r
Facility Owner
3s 61unt �o�oti's Lor�c
` '—" �a� Street Addres or Lot#
YarMo��b, �� �'� Ua6�y
CitylTown State Zip Code
�a OF rt�,Ess Designe/r Information:
S�E"�' � '�' 7
�: �ef rey N�. }{usY'�f , j�t Nlar>e �ny;nee�;,�y
� JEFFF:EV�1- �,�
g NAS5ETT . � Name Nameof omy any
� 10�2/�3
g CI'�HL "'
A No.492°3 � ig t e oate–�r
�
��.� R�GIS'fER�'�G� staller Information:
�SS/On;9�_�•
`g�`�� Name . Name of Company
Signature Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Approving Authonty
Signature Date
t5form3.doc•O6/03 Certificate of Compliance•Page 1 of 1
DESC. '
SEPTIC
SEPTIC
START
END
START
END
TANK
S'''TANK
D -BOX
ROW 1
ROW 1
ROW 5
ROW 5 `
IN
OUT
3S AUNT DQRAH'S LANE
A
37.0'
40.5'
31.0' '
29.3'
52.8'
38.3'
58.2'
B
49.0
51.5'
19.5'
,17.0'.:'
: 39.0
25.8'
43.5'
HEALTH OErT,,
SCH
PREPARED BY.•
PRoJEeT. SEPTIC SYSTEM AS,.BUILT PLAN
I CERTIFY THAT THE SEPTIC SYSTEM INSTALLED
{
3S AUNT DQRAH'S LANE
AT 35 AUNT DORAH'S LANE, SOUTH YARMOUTH, MA
HAS BEEN BUILT IN ACCORDANCE WITH TITLE- 5 OF THE
STATE SANITARY, CODE, THE BOARD OF HEALTH
F
�`��F ti' `
,�, s'
(ASSESSOR S'MAP 136, LOT 56
3-105
UA
JF
RULES & EGULATIONS AND `THE DESIGN PLANS.
o' JC=FFRCY 81.`�
`_ _ n
H�SCTi rn
MORSE
YARMOUTH, MASSACHUSETTS
a t
a .
v 0`'`1L `
No 4-)293
42.12N
7U. W
PREPARED FDR: BASS RIVER TRUST
ENGINEERING CO., INC.
P.E. r,°`
\ti�
�F` °` u/^TARE ra�
19 UNION STREET
1001 MNGHAM STREET..SHEET:
nr ^ r���,
P.O. Box 92
MA 02066
ROCKLAND, MA 02370
> F
SCITUATE,
(78I) 54 - 9s
PLAN TITLE:
SEPTIC SYSTEM AS -BUILT PLAN
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