HomeMy WebLinkAboutCheckList - As-Built Plan / Installation Certificate Form - 65 OLD CART WAY 6/25/2024 (C)J U/u- ('a r-t� 6va.5K
' Town of North Andover — Septic System - AS-BUILT CHECKLIST
1) v All changes to the design plan have been reflected and noted on the as-built plan
`� As-built plan has a suitable scale; (1 inch=40 feet or fewer for plot plans)
3) V Street Address,Assessor's Map and Lot Number
4) Lot Lines and Location of Dwellings served by the system
Locations,Elevations and Dimensions of As-built system components,including reserve(if applicable)
6) y Ties to all tank openings,d-box,and leach area from dwelling or Permanent Structure
7) �Setback 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
$) —L.Iocations of Wells,Drains,Wetland Resource Areas within 150 feet of system
9) -ALLocation of water,gas,electric lines,cable,control panel (if applicable)
10 ./ Location of Structures within 6 Inches of Finished Grade
11) -/ Original Stamp&Signature
q TLocation and holder of any easements which could impact the system
13 tIm ervious Areas;Driveways,etc
p � y
14) North Arrow
l� Location 8c Elevation of Benchmark used
16) rSTAMMENT ON PLAN (NA 5.3)
a. '/ "I certify the locations, elevations,ties,cover material;exposed component covers etc,
shown on this as-builtsubstentiallyage with the approved plan and have determined that the
break out elevations,if applicable,have been met"
I-I--I I
Shnifi&e of Designer Date
b. 19fa SYUCTURAL WALL ISPRESFdVT(NA 4.9)a Letter or statement on the as-builtin&catixr1t
the wall-weir or was not,constructed in accordance with the intended design and any
manufacf ur s specifications 1
Signature of Designer Date
As of-,Tuesday,March 17,2015
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