HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 101 FOSTER STREET 10/15/2021 jt 04
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PUBLIC HEALTH DEPARTMENT
t�enaarawalay trasaaraat Ir��relsra�nr
11OWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTAtlLA".l"T.(1k""w1 CERTIFICATION
The a aarcfmif4rrecf hereby,cca(ily that tlrc Sewage Disposal System constructed, � �acLmalrecB'>'
ti J ate es orcaczek�
�__.. (print haste)
Located at:1011 Foster Street
�L�tsta6R<mRlcarr a 'ddress)
Was instalted lrr conrraatra<ance Nvilh file North Aracic vu,lfcmaard of 11caith approved plan,originally dated
JWY 24,.2020, aarrrl latart mwawist,cf ratr At, u t 24, 2020 with ar dcslgaa ftwawv of
40 11 G all oar- _.gat'lcwras per day. 11iie maatcrlals used were in confcrraaraancz w ilh those specified on the
approved plan;the system was installed lrr accordance wwiRh the larcawriskins of'I 10.CMR 15,0 N,111le 5 and local
rogtflaatllaarms,aaaaaf tlac filial grading aq.Lrecs sarbstraatlafly Mflii the approved plan, All work is acematclsy represented on
the As.-built which has lrocm.n sm.wl mated to the 13card of i lawaaltlr.
Bottom of Bed lraspiveticrrr
Engineer Representative(Signature)
And l rintNaame
f : . t
f�"feral Construction ras�lacell�rr � r
Engi rc.ca•Repr eseutntrwe(t"s gna trrr e)
elijaarm ill C. 0 eaarl fr.,
And. Print Name
Installer. ...�' �Laigrrartrrre) frtatc 2 23J
Andt'rrnt Name ,
( lrtatq�aa ) 1)4ta�;,.. __:... .
�p __ _,...._. a
LLw�.L.�_ �a.r
And_.f'"rint Name
120 Main Street, North Andover, Massachusetts Oil8�45
Phome 978.688.9540 Fax 97 .6,88.9542 Wage fir^hip'://www.tioarllarttndlovefiitti.gov
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PUBLIC HEALTH DEPARTMENT
tunuruuun ty&Ewnamic Lleveloprnenr
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL,SYSTEM EM—INSTAIJ,A":>C ION CERTIFICATION
The undersigned hereby cci°tify that the Sewage DislrOstul Systa°rrr ccaurs°truucted; rcpauired;
Byedarnes E3er ek
_ _.----- ..._..........
(Print Naine)
Located at:101 Feaster Street
(Installation Address)
Was installed in conformance with the North Andover board of Ilealth approved plan,orl iunally dated f
July 24, 00 __..._and last revised oil„Au List m4, t} ..__ _. ....,with, tle,riruflow l`
440 Gallons gallons per day. The Materials rased were in confonnaunce with.those specified cn the
approved plan;the system was Jinstalled in accordnurce with the provisions of 310.C MR I5w000,Title 5 and local
re,g4lations,and the final grading agrees substantially with,the approved_plap.All work is accurately represented on
the As-built which has been submitted to the Board of I-lealth.
Bottom of lied Inspection Data:_...�._� ....
C"ny ineer ltepresruutative (Signature)
And Print Name
I"'luual Construc(ion Inspection IJwte. ......_..28,
020
Engineer Representativegnatuare)
Benjamin C. sad, r
r
And- Print I^Naurre
Installer-
,. ...�...._.. _.�_ ._..y__.�..( ignastnre)
And_Print Name
u,n ineerµ ti .. .::W _ (Signature) Dane:_,___ Z=/ - _,
And m---print Plante
120 Multi Street, North Andover, Massachusetts 01845
Phone 9 8,688,954t1 Fax 97 8.688,9542 Web fittp,-//www.tiortIlittndovernia.gov