HomeMy WebLinkAboutChecklist - As-Built Plan / Installation Certificate Form - 250 ABBOTT STREET 9/26/2022 2.50 �' bh0 j-1 S4 r'-4ZPq
Town of North Andover — Septic System - AS-BUILT CHECKLIST
1) z A11 chmiges to the design plan have been reflected and noted on the as-built plan
2) ✓ As-built plan has a suitable scale; (1 inch=40 feet or fewer for plot plans)
3) 'V Street Address,Assessor's Map and Lot Number
4) ' Lot Lines and Location of Dwellings served by the system
5) -Z.-Locations,Elevations and Dimensions of As-built system components,including reserve (if applicable)
6) /Ties to all tank openings,d-box,and leach area from dwelling or Permanent Structure
—/—Setback distances are shown on the as-built plan from system components to:
Z!x' Subsurface,interceptor&foundation drains
N A Catch basins
Property lines
wellings or other structures
,j -Private water supply or irrigation wells
Watercourses or wetlands
/ N/A n"i A
8) V Locations of Wells,Drains,Wetland Resource Areas within 160 feet of system
/ J
9) `� Location of water,gas,electric lines;eable;control panel (if applicable)
10) `/ Location of Structures within 6 Inches of Plnished Grade
11) Original Stamp&Signature
12) Location and holder of any easements which could impact the system
13) ✓ Impervious Areas;Driveways,etc �.—Y—
14) North Arrow
q /Location&Elevation of Benchmark used
10 STATEMENT ON PLAN (NA 5.3)
a. 'T cerfify the locations, elevations, fies,covermate6d;exposed component covers eta,
shown on this as-builtsubstanhallyagzve with the approvedplan andhave determined that the
break out elevations,ffapplrcable,have been met."
Signature of Designer Date
b. `Ta STUCTLIRAL WALL ISPRESENT(NA 4,9)a Letter or statement on the as-bzzdtJndicatinz
the wall-was,or was not,constructed in accordance with the intended design and any
manufach rer's specifications"
Signature of Designer Date
As of:Tuesday,March 17,2015