HomeMy WebLinkAbout- As-Built Plan / Installation Certificate Form - 199 OLD CART WAY 8/11/2022 .ctn
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: H&q �' �I'`
(Print Name)
Located at:_ cc V'-4-
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
r FIEvq u.
2'-L=�yZZ� and last revised on 3" Z -2'x- f 0,.;-Z-X.- ,with a design flow of
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: 2 'j� �-
Engineer Representative(Signature)
And-Print Name
Final Construction Inspection Date:_ �7r2
Engineer Representative(Signature)
And-Print Name
Installer: (Signature) Date:
And-Print Name
Engineer:
.(Signature) Date: ��'�2-%
tom
And-Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northaiidoverma.gov
SUMMARY OF INVERTS BUILDING TIES
SEWER 0 FDTN. PRE-EXIST. BLDG. CORNER A I B C D NOTE: THIS PLAN & CERTIFICATION IS NOT
SEPTIC TANK IN 184.62 SEP11C TANK IN 12.7 34.6 - - A WARRANTY OF THE SUBSURFACE DISPOSAL
SEPTIC TANK OUT 184.32 SEPTIC TANK OUT 19.8 38.5 - - SYSTEM. IT IS A RECORD OF THE LOCATION
DIST. BOX IN 182.75 DIST. BOX 21.8 45.0 - - AND ELEVATION OF THE EXISTING SYSTEM
DIST. BOX OUT 182.57 COMPONENTS.
LEACH LINE BEG 182.51 "1 HEREBY CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL,
LEACH LINE END 182.37 EXPOSED COMPONENTS ETC., SHOWN ON THIS AS-BUILT SUBSTANTIALLY
AGREE WITH THE APPROVED PLAN AND HAVE BEEN DETERMINED THAT THE
*NOTE•FIELD CHANCE DUE TO LEDGE IN BREAK OUT ELEVATIONS, 1F APPLICABLE, HAVE BEEN MET."
THE ORIGINAL EXCAVATION. LEACH FIELD WAS
RE-DESIGNED IN THE FIELD AS AUTHORIZED
BY STEVE CASEY N.A. HEALTH INSPECTOR IY��ft f i n'i� l� I(-7Z
SIGNATURE OF DESIGNER DATE
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AS BUILT PLAN
N
OF
c SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MASS./199 OLD CART WAY
0
AS PREPARED FOR
PAUL DALEY TM: 10;B
DATE: 8-9-22r■I
z ADIMIR L. s SCALE: 1"=40' TL: 108 0 ?o 40 80
RNEMCHENOK N
g MERRIMACK ENGINEERING SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
8/12/22,7:34 AM Daley 002.jpg
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SAWN Of NO pp,R�M�N�
HEALTH
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;O repaired;
(Print Name)
Located at:
(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
31 3�
�1410 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 Name
Installer: 3y � (Signature) v 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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