HomeMy WebLinkAboutSigned Installation Certif - As-Built Plan / Installation Certificate Form - 50 JAY ROAD 4/3/2024 f
4IiD,6�a.
i'
PUBLIC HEALTH DEPARTMENT
(ommunity&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( )constructed;( )repaired;
By: James Boraczek
(Print Name)
Located at: 50 Jay Road, North Andover _
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
5/18/22 and last revised on 12/5/22 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 ----
Engineer Representative(Signature)
Inspection by town
And—Print Name
Final Construction Inspection Date: August 28, 2C (= �/`
Engineer Representative gnature)
Benjamin C. Osgood, Jr.
And—Print Name
Installer: Signature) _ Date
4O.PhY.S 1-30"t<2CC
And—Print Name
Engineer:_ (Signature) Date:-
— -- _-- —_ - And—Print Name j
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web littp://www.tiortlinndoverma.gov