HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 487 WINTER STREET 8/30/2019 ¢�rcLED,4` RF
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PUBLIC HEALTH DEPARTMENT
(ommunily&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System A,)constructed;( }repaired;
By: it)
(Print Name)
Located at:J�y,�7
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
C,
and last revised on 7 - _,with a design flow of
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.ClAR 15.000,Title 5 and local
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the As-built which has been submitted to the Board of IIealth.
Bottom of Bed Inspection Date:
Engineer Representative(Signature)
-1`i r!'f f � ' A_�
And-Print Name
Final Construction Inspection Date:
Engin epresentative(Signature)
And-Print Name
Install * -(Signature) Date: 8/13/2019
And- Print Name
Engineer: (Signature) Date: - j q /
And-Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandovernia.gov