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Plum Island Water and Sewer Project
Water & Sewer Connections
Certification as to Compliance Date:_______________________
By signing this document, the Owner of the property at ___________________________
In the City of Newburyport/Town of Newbury (cross out inappropriate community) and the contractor who installed the water and sewer connection at the above address hereby certify as follows: (check all appropriate)
 ___The house connection for the water system was installed, cleaned, and tested per the specification requirements.
 ___The pre-existing well and pump was decommissioned and disconnected from plumbing system per specification requirements and there is no cross connection between public supply and any private well per State Regulations 310 CMR 22.2.
 ___The house connection for the sewer was installed, cleaned and tested per the specification requirements (attach copy of air pressure report).
 ___The existing septic system has been decommissioned in accordance with State Regulations 310 CMR 15.354.
 ___Conditions, as required by the Order of Conditions (Town of Newbury File Number 050-594) as supplemented by the Conservation Agent, have been met.
 ___Homeowner certifies that water conservation devices as given to homeowner by Newburyport Water Dept. at time of application have been installed.
Property Owner |
Contractor |
Licensed Plumber |
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Signature
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Signature
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Print Name
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Print Name
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Print Name
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Name of Firm
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Name of Firm
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Name of Firm
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Address
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Address
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Address
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Phone Number
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Phone Number
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Phone Number
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License Number
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