HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 997 DALE STREET 11/12/2019 o •
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PUBLIC HEALTH DEPARTMENT
(ommeelty L Ecoeoink Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(Vlonstructed;( )repaired;
C� (Print/Name)located at: / U a—/�/
_
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
-20/2 _and last revised on_7 _ ' 001 ,with a design flow of
>O� _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: _
Engineer Representative(Signature)
And—Print Name
Final Construction Inspection
Engineer Representative(Signature)
And—Print Name
Installer: _(Signature) Date: r'
And—Print Name
I:nFinecr: __(Signature) ^ Date: /!/8/�___
And—Print Name
120 Main Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov