HomeMy WebLinkAboutChecklist - As-Built Plan / Installation Certificate Form - 50 HAY MEADOW ROAD 9/11/2024 sd //a,/ 1��WoO
Town of North Andover — Septic System -- AS--BUILT CHECKLIST
1) V rAs-buflt
changes to the design plan have been reflected and noted on the as-built plan
plan has a suitable scale; (1 inch=40 feet or fewer for plot plans)
s
3) 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
?} 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
c f e e Areas 1 0 fee of stem
8) Locations o Wells,Drams,Wetland Resource within 5 t system
9) Location of water,gas,electric lines,cable,control panel(if applicable)
10) Location of Structures within 6 Inches of Finished Grade
11) Original Stamp&Signature
12) TLocalion and holder of any easements which could impact the system
13 7 Impervious Areas;Driveways,etc
1- TNcrth Arrow
1 cation&Elevation of Benchmark used
16) STATEMENT ON PLAN(NA 5.8)
a. `T cerffy the locations,elevations, ties,covermaterial;exposed component covers etc.,
shown on this as harltsuhstantrsTlyagree with the appmvedplan andhave determined that the
break out elevations,zf applicable,have been met.n
Signature of Designer Date
b. "Ya STUCTURAL WALL IS PRESENT W 4.9)a Letter orstatementon the as huiltindicatitt�
the wall-ores.or was not,cottstrueted 1n accordance with the Intended design and any -- r
manufacturer's specifZcation s"
Signature of Designer Date
As of:Tuesday,March V,2015
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