HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 740 FOREST STREET 8/9/2021 Ali
RECEIVED
1W PUG 0 9 2021
TOWN OF NORTH ANDO��
PUBLIC HEALTH DEPARTMENT Tk1 DEPARTMENT
Community&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM-INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( )constructed;NQ repaired;
By: MArs< i tNtd --TVkE: }-1QNicf, C19 Q \
(Print Name)
Located at: -:�4"O 'FO(LIST ST?-Ez 1 -
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
12( IS I20 ZO and last revised on 3 1 (ZOZ-� ,with a design flow of
440 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: 25 10
Engineer Representative(Signature)
And—Print Name
Final Construction Inspection Date:
Engineer Represe ative(Signature)
- \N%LI_ SGNk,JTjq I P��
And—Print Name
Installer: Signature) Date: rJ� /
oC F O
And—Print Name
Engineer: -!M Me4-A4Ao _(Signature) Date:=lT/ZQ Z 1
C. t-A o r 1;n
And—Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov