HomeMy WebLinkAbout- As-Built Plan / Installation Certificate Form - 404 SUMMER STREET 1/24/2019 i
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PUBLIC HEALTH DEPARTMENT
(OR11111mil'&tc0110011(Develo11mell1
TOWN OF NORTH A ROVER
ASEPTIC;DISPOSAL SYSTEM---INSTALLATION CERTIFICATION
"l"he undersigned hereby ec►•tify that the Sewage Dispnosal.System(5C)constructed;( )repaircd;
By;_ John Chongris___.______..__.._...
(Print Name)
Located at: 404 Summer St.
(Installation Address)
Was installed ill Coll finr111alice with tine North Andover Board of Health approved plan,originally stated
...._._-.........._and last revised oil February 22 2018 with a design flow of
' ......
..__gallons per day. 'I"lie materials uscd were in conformance with those specified on the
approved plan;the system was installed in accordance with the provisions of310. C ivllt 1 MOO,'Fitle 5 and local
regulations, and the final grading agrecs substantially with the approved plan.All work is accurately represented on
the As-built which has been submitted to the Board of I lealth.
Bottom of Bed Ins eetion Date: 912011$
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Engineer Itep1 eselut:�.�V';' Signature)
Douglas Smith
And—Print Name
Final C,oanstrnctiona Inspection Date: 10/1 18 � r
Engineer Reinresen#a nve(Signature)
Douglas Smith
Ancl _ Print Name
Installer:
l ✓cF C"r (Signature)
Date
And--Print Name
Engineer:
Date: 12/19l1$
And -Print Name j
120 Main Strout, North Andover,r, Massachusetts usetts 01845
Phone 978. 8 .9540 Fox 970. 1.10.9'54 Web littt)://www.noi,tliantloveriiia.gov
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Town of North Andover — SW c 5 shem - AS-BUILT CHECKLIST
1) All changes to the design plan have been reflected and noted on the as-built plan
2) X As-built plan has a suitable scale; (1 inch= 40 feet or fewer for plot plans)
3) Street Address,Assessor's Map and Lot Number 1
4) X Lot Lines and Location of Dwellings served by the system
5) X Locations,Elevations and Dimensions of As-built system components,including reserve (if applicable)
6) !—Ties to all tank openings,d-box,and leach area from dwelling or Permanent Structure
X Setback distances are shown on the as-built plan from system components to:
X Subsurface,interceptor&foundation drains
n/a Catch basins
X Property lines
x Dwellings or other structures
n/a Private wafter supply or irrigation wells
X Watercourses or wetlands
8) _X Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system
9) .X Location of water,gas,electric lines,cable,control panel (if applicable)
10) _X_Location of Structures within 6 Inches of Finished Grade
11) X Original.Stamp&Signature
12) n/a Location and holder of any easements which could impact the system
13) X Impervious Areas;Driveways,etc
14) X North Arrow
15) X Location&Elevation of Benchmark used
16) X STATEMENT ON PLAN (NA 5.3)
a. X 'T certify the locations, elevations, ties;cover material,•exposed component covers etc.,
shown on this as-built substantially agive with the approvedplan and have deterrrrined that the
break out elevations,if applicable,hi e been met."
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Si ature of Design r Date��—T�
b. n/a "Ifa STUCTURAL WALL H PRESENT W 4.9)a Letter or statement on the as-huilt indicatinz
the wall-- was, or was not,constructed in accordance with the intended design and an y
manufacturer's s aecif cations."
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Signature of Designer Date
As of:Tuesday,March 17,2015