HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 218 LACY STREET 10/13/2020 �G 0
S�-o�No�Q
-\(3\
\�
PUBLIC HEALTH DEPARTMENT
Communi y&Ecanemic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System: q constructed;( )repaired;
(Print Name)
hocated at:
(Installation Address) —
Was installed in conformance with the North Andover Board of Health approved plan:originally dated
and last revised on c�1r j _ _ _ 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 i 10.CNMR i 5.000,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. 'l
F !
Bottom of Bed Inspection Date:
Engin rV epr Iat tgnature)
And—Print Name t
U
Final Construction Inspection Date:_
Gngi� r Re resent r•e(Signature)
And--Print Name
o�:tea --�,'�-2` -w✓
Installer: (Signature) Date:�a�
Atd--Print Name
Engineer: ' (Signature) Date•
l
t And -Print Na me
120 Main Street, North Andover,Massachusetts 01845
Phone 978.688.9540 fox 978.688.9542 Web http://www.northandoverrin.gov