HomeMy WebLinkAboutchecklist - As-Built Plan / Installation Certificate Form - 459 SALEM STREET 11/17/2022 z/5-? -5�t,le-/),) 74
Town of North Andover — Septic System - AS-BUILT CHECKLIST
1) '/�' 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)
:569
3) + Street Address,Assessor's Map and Lot Number C N
18IV-
4) ✓ Lot Lines and Location of Dwellings served by the system
5) /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:
✓Subsurface,interceptor&foundation drains
__(2ff)Catch basins
Property lines
Dwellings or other structures
Private water supply or irrigation wells
NA_Watercourses or wetlands
Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system
9) ✓ Location of water,gas,electric lines,cable,contanel (if applicable)
18) i/ Location of Structures within 6 Inches of Punished Grade
\/11) Original Stamp&Signature
12) j �Location and holder of any easements which could impact the system
13) Zimpervious Areas;Driveways,etc
14) V North Arrow ,
15 ✓Location&Elevation of Benchmark used
16) STATEMENT ON PLAN (NA 5.3)
a. 'Q certify the locations, elevations,ties, covermatetral;exposed component covers etc.,
shown on this as-huiltsuhstantiallyagree with the approvedplan andhave determined that the
break out elevations,if applicable,have been met,"
Signature of Designer Date
b. `9fa STUCTURAL WALL ISPRb`SENT(NA 4.9)a Letter or statement on the as-ha ltindicatinst
the wall--was,or was not,construdedin accordance with the intended design andany
many lactatur's sbecif cations"
Signature of Designer Date
As of.Tuesday,March 17,2015