HomeMy WebLinkAbout- As-Built Plan / Installation Certificate Form - 990 JOHNSON STREET 11/19/2022 PEGSOO
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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(,4nstructed;( )repaired;
By:
(Print Name)
Located at:
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(Instal ation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
_ mow and last revised on I--?/ ,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.
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Bottom of Bed Inspection Date: Z7/
Engineer Representative(Signature)
And—Print Name
Final Construction Inspection Date: 2�
Engineer Representative(Signature)
V2 1 L li PLk r 49'4;
And—Print Name
� —nstailer: N (Signature) Date:
And—Print Name
i, (Signature)
Engineer: 'p-- VL e ��nI I
And—Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov