HomeMy WebLinkAboutSigned Installation Certification - As-Built Plan / Installation Certificate Form - 463 WINTER STREET 10/26/2022 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;
By: C T�L,o�J6 k's PTZC� c�,v-i'�4t 2 t'�G
(Print Name)
Located at: AL 3 LJ p^ MJZ
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
;51 Z bZL and last revised on 5 31 ZQ ZZ, 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: zZ
Engineer Representative ignature)
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And—Print Name
Final Construction Inspection Date: (9 -.z
/ Engineer Representative(Signature)
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And—Print Name
Installer: (Signature) Date:
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://www.northandoverma.gov
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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;
By: Ck4 'Ta61""Sy/l
(Print Name)) 1
Located at: —7 6 3 M,k-r S4 f exA
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
3/-7 A0a-)- and last revised on 3 3Ax6l)_ with a design flow of
Y(/0 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:
Engineer Representative(Signature)
And—Print Name
Final Construction Inspection Date:
Engineer Representative(Signature)
And—Print ame 1
Installer: (Signature) Date: r 0 J �2,;2-
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://www.northandoverma.gov