HomeMy WebLinkAbout- As-Built Plan / Installation Certificate Form - 288 FOSTER STREET 11/7/2022 o ( 1
t�WN
KEG
PUBLIC HEALTH DEPARTMENT
fa�nmunity 8 Etnnamic pEvutopntenl
TOWN OF NORTH ANDOVI;R
SEPTIC DISPOSAL SYSTEM—INSTALLATION CEWFIFICA'IYON
The undersigned hereby certify that the Sewage Disposal System(-constructed;( )repaired;
G
(Print Haute)
Located at:
(Installation Address)
I
Was installed in contormance with the North Andover Board of Health approved plan,originally dated
I&Lalp -Z11 and last revised on 1 1— 4-1 Z� ,with a design flow of
. 'T y gallons per day. The anateriuls 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 lied Inspectionce �__ V
Date;�f• i'ZrZ __
�.ngineer Representative(Signature)
And—Print Name
Final Construction Inspection Date:t_�2—__WJ"7V
Cat iticer�yresentativa SI nature
[� g 1 ( f ?
And—Print Name
Installer: (Signature) Date:
And—Print Name
Engineet:���{I�)R,(��}�'r���.� __(Signature) bate;
And Print Name
120 Main Street, Noith Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web littli;j/www.ndrtiiiiiidovernia.gov
• 7
SEP 2 �2022
ANoovEa
1040A Of H DS9 SMEN�
PUBLIC HEALTH DEPARTMENT
(ammunily&Economic Developmeal
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(constructed;( )repaired;
By: ,f OJN L
(Print Name)
Located at: Z kXfi
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
le-0—y and last revised on I ,with a design flow of
"1+d 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 Lcspection Date:��•- j'2iZ �ca, Qf
Engineer Representative(Signature)
L, OQ rr
rL
And—Print Name o
Final Construction Inspection Date:
Engineer Representative(Signature)
And—Print Name
Installer: (Signature) Date:
0
And—Print Name
Engineer:/ a / � (Signature) Date:
11LIVi d!z- -FDIC'14e'A_2_a
And—Print Name
120 Main Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandovernia.gov