HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 1565 SALEM STREET 6/22/2021 ti
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PUBLIC HEALTH DEPARTMENT
(ommunily&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( )constructed;( }repaired;
By: --�: f 41Ar5 cn
(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 �Y��l ,with a design flow of
p 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.
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Bottom of Bed Inspection Date: &
Engineer Representative(Signature)
And—Print Name l
Final Construction Inspection Date:
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INS Engineer Representative(Signature)
And—Print Name
Installer: � (Signature) � Date:1 af/ry/oT-��
A —T.
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