HomeMy WebLinkAboutInstallation Inspection - As-Built Plan / Installation Certificate Form - 1 SCOTT CIRCLE 7/27/2022 •-
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PUBLIC HEALTH DEPARTMENT
Community&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed;( )repaired;
Bv: ----
(Print Name)
Located at:--I_G7�����(��'� -- —
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
and last revised on with a design flow of
^gallons per day. 'fhe 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:
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Engineer Repres tative(Signature)
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`— � --And—Print Name 'J f
Final Construction Inspection Date: ���`�
�j jet Engineer Representative(Signature)
And—Print Name
Installer: (Signature)
Date:
And—Print Name
Engineer:— t :L�-l�f:Lt�1 (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