HomeMy WebLinkAboutChecklist - As-Built Plan / Installation Certificate Form - 199 OLD CART WAY 8/9/2022 i 9 9 O/d, CO-/_7'
Town of North Andover— Septic System - AS-BUILT CHECKLIST
1) All changes 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) Street Address,Assessor's Map and Lot Number
4) Lot Lines and Location of Dwellings served by the system
Locations,Elevations and Dimensions of As-built system components,including reserve(if applicable)
6) Znes 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:
_Subsurface,interceptor&foundation drains
NI,FCatch basins
Property lines
—7 -Dwellings or other structures
77Private water supply or irrigation wells
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/ atercourses or wetlands
8) Locations of Wells,Drains,Wetland Resource Areas within ISO feet of system
/ ,r,�l, qh Nil® '
9) Location of water,gas,electric lines,cable,control panel (if applicable)
10) ✓ Location of Structures within 6 Inches of Finished Grade
11) ✓ Original Stamp&Signature
12) /✓/ Location and holder of any easements which could impact the system
13) `/Impervious Areas;Driveways,etc
14) ✓ North.Arrow ,
q Location&Elevation of Benchmark used
16) ✓ STATEMENT ON PLAN (NA 5.3)
a. / `T certify the locadans, elevations, ties,covermaterW;exposed component covers etc.,
shown on this as--huiltsubstanhally agree with the approvedplan andhave determined that the
break out elevations,ifapplicable,have been met."
Signature of Designer Date
b. `Qfa STUCTURAL WALL IS PRESENT W 4.9)a Leiter or statement on the as-ha dtindica ' g
the wall- was,or wasrrot constructedin accordance with the intended desi g anv j?and
manadacftuvr's specifications"
Signature of Designer Date
As of:Tuesday,March 17,2015