6 CEDARCREST ROAD TITLE 5 CERTIFICATE OF COMPLIANCE L\ Commonwealth of Massachusetts
City/Town of Salem
w° 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
Important:When
filling out forms ❑ 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 done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
key.
DSCP Number DSCP Date
Dion Realty Trust
Facility Owner
6 Cedarcrest Road - - -- - - —
Street Address or Lot#
Salem _ MA_ 01970
Cityrrown State Zip Code
Designer Information:
N/A _ N/A - -
Name Name of Company
_N/A
Signature - — Date - -
Installer Information:
Jo_nat_han G_ranz Preventative Septic _-
Name Name of Company
7/22/23
Q,:,nar c 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.
..S)_ L �� ��° /4 J6o'L
Approving utho
a o_o �
Signature Date
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