HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 734 Boxford Street 12/9/2021 PUBLIC HEALTH DEPARTMENT
(ommunily&Economic Development
TOWN Or NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(X)constructed;O re a
�a-
Y aired;
B ; Tom Sawyer �i/ /.
(Print Name)
Located at: 734 Boxford Street
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
January 12, 2021 and last revised on March 22,2021 ,with a design flow of
550 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.CbAR 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: 11/9/2021
Engin er Representative(Signature)
Benjamin C. Osgood,Jr.
And—Print Name
Final Construction Inspection Date: 11/18/21
Engiz eer Representative(Signature)
Benjamin C. Osgood,Jr.
And—Print Name
Installer: (Signature) Date:
And—Print Nanie
Vngineer:'=� G ! (Signature) Date:
� -Y�C?M
And—Print Name
120 Main Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov
PUBLIC HEALTH DEPARTMENT
Community&E;onomi(Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL,SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed; ( )repaired;
By:�L lh yjz/if-, TIC.
(PAht Name)
Located at: 3 $QY Q)2b
(Installation Address)
Was installed in conformance with the North Andover JBoard of HeaM approved plan,originally dated
and last revised on 3l Z Z�Z ,with a design flow of
5 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:-[ ' I Z'
Engineer Representative(Signature)
And—Print Name
Final Construction Inspection Date:
Engineer Representative(Signature)
And—Print Name
Installer: ' (Signature) Date:_
T. Sawa
irl 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:J/www.northandoverma.gov