HomeMy WebLinkAbout- As-Built Plan / Installation Certificate Form - 125 GRAY STREET 11/1/2023 PUBLIC HEALTH DEPARTMENT
(ommenity 3 Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System(constructed;( )repaired;
By:
(Print Name)
Located at: �i�IZf�Y /Kr1_ft`i"(
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
q—] 'j—'li and last revised on ,with a design flow of
4q-19 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: �1' �'� ag
Engineer Representative(Signature)
Vjl Lk
And—Print Name
Final Construction Inspection Date:��
Engineer Representative(Signature)
And—Print Name
Installer: ignature) Date:
�) And—Print Name
Engineer:/f' /V�L(1 � (Signature) Date:
And—Print Name
120 Main Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov