HomeMy WebLinkAboutSeptic Installation Form - As-Built Plan / Installation Certificate Form - 865 JOHNSON STREET 11/24/2025 • '�„��• , Town of Norti i Andover
DEC - 312025
Health Department
PUBLIC HEALTH DEPARTMENT
(ommunity&Economic Development
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION:E TIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed;( )repaired;
By: f��,J�l yirAr
(Print Name)
Located at:_
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
Z4 and last revised on %' ,with a design flow of
L140 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)
And—Print Name
Final Construction inspection Date: =7Z
Engineer Representative(Signature)
Y�w ,a
And—Print N ne
Installer: A,, Date: 4-/
And—Print Name
Engineer: �t1��y� r1 � (Signature) Date:
And—Print Name
120 Main Street, North Andover, IVIassuchusetts 01845
Phone 978.600.9540 Fax 978.688.9542 Wei) littp://www.northandovei,ma.gov
Town of North Andover — Se tic S stem AS-BUILT CHECKLIST
1) All changes to the design plan have been reflected and noted on the as-built plan
2) As-built plan has a suitable scale•, 0 inch = 40 feet or fewer for plot plans)
3) 46treet 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 Town of NoII' il AndoverCatch basins
Property lines
Dwellings or other structures
Private water supply or irrigation wells DEC ® 3 2025
`� Watercourses or wetlands
8) V Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system Health Department
9) �967�t�.�.,o���,�o4�e�,gas,electric lines,cable,control panel (if applicable)
10) _, Location of Structures within 6 Inches of Finished Grade
11) ✓ Original Stamp&Signature
12) Z Location and holder of any easements which could impact the system
13) L Impervious Areas;Driveways,etc
14) North Arrow
15) 7Location&Elevation of Benchmark used
16) STATEMENT ON PLAN (NA 5.3)
a. "I certify the locations, elevations, ties,cover material;exposed component covers etc.,
shown on this as-built substantially agree with the approved plan and have determined that the
break out elevations,if applicable,have been met."
Signature of Designer Date
b. "If a STUCTURAL WALL IS PRESENT(NA 4.9)a Letter or statement on the as-built indicatinz
the wall- was, or was not,, constructed in accordance with the intended design and any
manufacturer's specifications."
Signature of Designer Date
As of:Tuesday,March 17,2015