HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 204 MILL ROAD 4/16/2020 Y 4
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PUBLIC HEALTH DEPARTMENT
tonmunlly&Economic Dowelopment
TOWN OF NORTH ANI9IJDVER.
SEPTIC DISPOSAL SYSTEM--INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System Q9 constructed; repaired;
By; Bateson (Enterprises �._.._
(Print blame)
Located at: 204 Mill toad
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated.
/I 19,01 Q and last revised on 5/29/ 019 „with a design flow of
gallons per day. The Materials used were in contoarraance with those specified on the
approved plan„the system was installed in accordance with the provisions of 31Ol CMR 15.000,Title 5 and local.
regulations,and the final grading agrees substantially with the approved pl All wont is accurately represented on
the As-built which has been submitted to the Board of Health.
Bottom of Beal Inspection Date: 4 120
E4 ngi7r It tative(Sig ure)
John,D, Sullivan hl, Ply
And---Print Name
Final Construction Inspection.Date 4/8/ 0
Engin Repr tative(Signature)
John D. Sullivan Ill
And—Print Name
W , ,..
Installs . (Signature) Date.
And—Print Name
Engineer: (Signature) Date:
And w Print Name
120 Main Street, North Andover,Massachusetts 01845,
Phone 978.688.9540 Fox 978.1688.9542 Web http./Jwwvw.northanwloverma.gov
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PUBLIC HEALTH DUARTli➢EHT
(olu aanity&Eeoaerott Development
TOWN N OF NORTH A N DOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( constructed; repaired;
By
(Print Name)
Located at: 204 Mill Road
(Installation.Address)
Was installed in conformance with the North Andover Board of Health approved plats,originally dated
and last revised on /29/201 ,with a design flow of
gallons per day. the materials used were in conformance with those specified on the
approved plats;the system was installed in accordance with the provisions of 3 1 O" MR 15.000,Title 5 and local
regulations,and the final grading agrees substantially with the approved plat 11 work is accurately represented on
the As-built which has been submitted to the Board of Health.
Bottom of B+�+d Inspection Date: 41712i1
ngf Ytative
(Sigire)
John D. Sullivan, ill„P ,
And—Print Name
Final Construction inspection Date: 4/8/2.0
Enginure)
Join D. Sullivan ill
And—Print Name
Installer- (Signature) late:
And 2iT
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Engineer: (Signature) Date: b e
� ��.
And—Print Name
120 Main Street, North Andover, Massachusetts 01845 �� -
hone 978.698.9540 Fax 978.688.9542 Web http://www.northaodoverma.gov