HomeMy WebLinkAboutSeptic Installation Certification - As-Built Plan / Installation Certificate Form - 1985 SALEM STREET 9/25/2019 R
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PUBLIC HEALTH DEPARTMENT
Community&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(/Constructed;( )repaired;
By. n /'il/-� 1 IVA 0
(Print Name)
Located at:
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
7 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.CMR 15.000,Title 5 and local
regulations,anU Lne 1 nal graUWg agree)JUDSMULlally Wllil U10 UI)PIUVCU p1Qi1.t.11 WUlri 1J aL. WdLely 11P10bV"OU U11
the As-built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:
5 (� V T-l/ gineer Representative(Signature)
./} M (- M
And—Print Name
Final Construction Inspection Date:
VTN ngineer Representative(Signature)
And—Print Name
Installer �-� Signature) Date:
And—Print Name
Engineer: _(Signature) Date: ! 7 `
And—Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov