HomeMy WebLinkAboutInstallation Certification - As-Built Plan / Installation Certificate Form - 42 JAY ROAD 8/2/2023 • 5�.{ZGLU��' •
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PUBLIC HEALTH DEPARTMENT
(ommunity&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(4 constructed;( )repaired;
By: J O H O f�1-k 1 T
(Print Name)
Located at: G{Zl Jm' &. A,P
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
,Y j V' 7i 2 and last revised on ,with a design flow of
(2 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
Engineer Representative(Signature)
And—Print Name
Final Construction Inspection Date:
� Engineer Representative(Signature)
13 Lt' R /
And—Print Name
Installer: (Signature) Date:
J�w
And—Print Name
Engineer: l 4& (Signature) Date:IF
And—Print Name
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov