HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 1995 SALEM STREET 7/2/2020 • h, RECEIVED
OCT 0 7 2019
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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:Dave Maynard
(Print Name)
Located at:1995 Salem Street
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
5/5/17 and last revised on 8/14/17 ,with a design flow of
550 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.
Bottom of Bed Inspection Date:9/9119
ngineer Representative(Signature) {
James Melvin, P.E.
And—Print Name
Final Construction Inspection Date:9/17/19 mil~ C
gineer Representative(Signature)
James Melvin, P.E.
And—Print Name
Installer: (Signature) Date:
t� And—Print Name
Engineer: �� (Signature) Date:
James Melvin, P.E.
And—Print Name
120 Main Street, North Andover, Massachusetts 0184S
Phone 978.688.9S40 Fax 978.688.9S42 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:
(Print Name)
Located at:
(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
regulations,anU t11e 1111a1 graUing agrees SuoSLanLlally W1L11 Ultl applUVOU p1da.t111 WUlll 1J 0.V WdWly MV1GJGllLGU 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
Install ignature) Date:
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