HomeMy WebLinkAboutCheckList - As-Built Plan / Installation Certificate Form - 30 MILL ROAD 5/3/2024 J /"), / // /10 CA.,(D(
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) X Street Address,Assessor's Map and Lot Number
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
JSetback distances are shown on the as-built plan from system components to:
Subsurface,interceptor&foundation drains
Catch basins
✓ Property lines
,._Dwellings or other structures
•✓ Private water supply or irrigation wells
-- Watercourses or wetlands
8) Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system
9) v Location of water,g\,%,elecX lines,ca�e,control panel (if applicable)
10) ✓ Location of Structures within 6 Inches of FXnished Grade
11) v Original Stamp&Signature
12) _ Location and holder of any easements which could impact the system
13} " Impervious Areas;Driveways,etc
14) ZNorth Arrow ,
15 Location&Elevation of Benchmark used
10 STATEMENT ON PLAN (NA 5.3)
a. �// "I certify the locations, elevations,ties,cover material;exposed component covers etc.,
shown on this as-built substanLWIjragive with the approvedplan andhave determined that the
hxeak out elevations,if applicable,have been met."
Signature of Designer Date
b. "fa SYUCTURAL WALL ISPRE`SLW(NA 4.9)a Let ter or statement on the as-built.indicatinz
e wall-wasz or was not,constructed in accordance with the intended design and any
manufacttxrer'sspecitications" .
Signature of Designer Date
As of;Tuesday,March 17,2015