HomeMy WebLinkAboutAs-Built Plan / Installation Certificate Form - 257 BOXFORD STREET 7/30/2018 -
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TOWN OF tit'll"~11"1.1l DOVI,i
PUBLIC HEALTH DEPARTMENT
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' 'OWN OF NC)RTf•I( ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The Undersigned hereby certify that the SewageDisposal System( )constructed;( )repaired;
By:.._......John Jablonski
(Print Name)
Located at: 257 Boxford St.
—w. _... _ _ ......... .. .............._............._._.......
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
June 2, 2018 and last revised on June 18, 201$ with a design flow of
440 gallons per clay. 'Flee materials used were in conformance with those specified on the
approved plana;the system was installed in accordance with the provisions of310. CMR 15.000,J'itle 5 and local
regulations,and the final grading agrees substantially with the approved plan.All work is accurately represented on
the As-built which has been submitted to the Board of Health,
I3ottorn of Bed Inspection Date; July 16, 201$
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Fnginecr I'tetaresenttive(Signature)
Douglas J. Smith
And--Print Name
Final Construction Inspection Date; July 18, 2018
Isngineer Representative(Signature)
Douglas J. Smith
And---Print Name
Installer: (Signature) Date:
And--Print Name
Engineer: �!� (Signature) Dane: July 25, 201$ 1
Douglas J. Smithm .__.___..._....._.___.___.._.._-..---_--
i
And--Print Name
g Main Str,eet, Nortiq Andover,Massachusetts 01845
Phone 978.688.9540 Fax 97'8.,688.9542 We littp-//www.nortl,iondovernin.gov
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PUBLIC Mail DEPARTmEN'r
TOWN OF NORTH ANIIbOVIi;IF
SEPTIC DISPOSAL SYSTEM—INSTALLATION C.'I+:RTIFIC"ATION
The undersigned hereby certify that the Sewage Disposal System( )constructed;( paired;
(Print Name)
Located at:._..- Z-57
(Installation.Address)
Was installed in confarmance with the North Andover Board of Health approved plan,originally dated
- t and last revised on Co e ' cs 1 with a design flow of
1 _.__-4 _.__. _�_. g
gallons per day. The materials used were in conformance with those specified on the
approved plan;the system was installed in accordance with the provisions of"310.CMR 15.000,Title 5 and local
regulations,and the final grading agrees substantially with the approved;plan.All work is accurately represented on,
the As-built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:.,__-7 � 2��'�e
Engineer Representative(Signature)
And-Print Name
Final Construction inspection Date:
Engineer Representative(Signature)
And-Print Name
.
Installer ..�,�v. ..v(Sngnatuie), Date:— t5- Z� {
And-Print Name
Engineer: (Signature) Date:
And-Print Name
120 Main Street, INorth Andover, Massachusetts 01845
Peons 978.6 8.9540 Fox 978,.688.9S42 Web http://www.nou°thandoverma.gov