HomeMy WebLinkAboutSigned - As-Built Plan / Installation Certificate Form - 65 OLD CART WAY 12/15/2023 0
PUBLIC HEALTH DEPARTMENT
(ommandy&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( )constructed;( )repaired;
By: --1 G 4-t/ --
(Print Name)
Located at: 6 S O IcIC c r1- w 0
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
and last revised on with a design flow of
y�0 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:.'M
Engineer Rep esentative(Signature)
!2LA -
And-Print Name
Final Construction Inspection Date: Iff
Engineer Representative(Signature)
And-Print Name
Installera� _ _(Signature) / Dater/ -Y O o2
i And-Print Name
Engineer:"NiZ _(Signature) Date: It�23
YL A V {�� l� Hi:�44-r- 0
And-Print Name
120 Main Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fox 978.688.9542 Weh http://www.nortliandoverma.gov
�'7 y
�;f
rd _._ - - -.. - _ ___.- _ _. _______ - _.-.__