HomeMy WebLinkAbout- As-Built Plan / Installation Certificate Form - 102 LOST POND LANE 6/28/2024 boae�
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PUBLIC HEALTH DEPARTMENT
(ommunity&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System0 constructed;( )repaired;
By: PfiI T/y"j
(Print Name)
Located at: I,C/ EW) P �L �?
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
Ij Z-'2 it and last revised on �7�7� ,with a design flow of
�yJO 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:
Engineer Representative(Signature)
LArr ��a
And—Print Name
Final Construction Inspection Date:01 W-1
Engineer Representative(Signature)
And—Print Name
Installer: (Signature) Date:
A.qn�d�—Print Name
Engineer: / T 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