HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 61 FOREST STREET 6/4/2020 •
PUBLIC HEALTH DEPARTMENT
Community&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(15 constructed;( )repaired;
By: Scott Cooke(Property Owner)
(Print Name)
Located at: 61 Forest Street
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
and last revised on �A h f ,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,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. 00011-1,
Bottom of Bed Inspection Date: 10-24-2019 /4p,
Enginee epresentative(Signature)
John D. Sullivan III, PE
And—Print Name
Final Construction Inspection Date: 11-1-19
Enginee r tative(Signature)
John D. Sullivan III, PE
And—Print Name
Installer: (Signature) Date:
And—Print Name
Engineer: (Signature) Date: 11-1-2019
John D. Sullivan III, PE
And—Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov
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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:�q�{r f3prgcLcoc
(Print Name)
Located at: ' &r) S
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
and last revised on ,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
regluaclons,anu ule llnal graulllg agrCCS SUDSMULlally W1U1 LUC aj)plUVCU jJlaU.till WUlh 1J dL:L:LUCLLOIy lVp1rib""MU U11
the As-built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:
Engineer Representative(Signature)
And—Print Name
Final Construction Inspection Date:
Engineer Representative(Signature)
And—Print Name
Installer• (Signature)� Date: /0'Z./"(�7
J rat F I �O,2 j1c 2 c-lir—
And—Print Name
Engineer: (Signature) Date:
And—Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov