HomeMy WebLinkAboutSeptic - As-Built Plan / Installation Certificate Form - 18 EQUESTRIAN DRIVE 6/17/2026 Town of Nofth Andover
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JUN 17 2026
4 Health Department
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PUBLIC HEALTH DEPARTMENT
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TOWN OF NORTH ANDOVE
SEPTIC DISPOSAL SYSTEM- INSTALLATION CERTIFICATION
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"t"l e a.aaaclea•sig ae l hereby certify that he Sewage Disposal Sy t na G4constructed; repaired
(Print Name)
Located gat;
—1fZ-- VO4V f�
taastaal laation Addrr ess
Was installed in confor naaace with the North Andover Board ofHealth approved plan,originally dated
as laa t aW�vi l itla a design flow of
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� 44 gallons pea,day. "I'lie materials used were in conforniance with those specified on the
approve plan; the system was i st lled iiii accordance with the provislons,of 31 . CMR 15.000,Title 5 and local
regulations, and the final grading,agrees substantially with the approved plan.All work is accurately represented over:
the As-built wla i la has been submitted to the Board t-caltla.
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Bottom of BedI� Inspection ate " '`
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And—,faint Name e0000,
Final Coaastaoaictlaia'taas,alect'oaa Date: e,
And Pi-i at Name
Installer: (Signattim) Date:
And—Print Name
ng I ilaattil,e Date,v IARL
And—Print Name
120 Main Street, North
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Toiwi of North Andover — SpptLic Svstern ,., AS-,BUILT CHECKLIST
1) All changes to the design plan have been reflected and noted on the as-built plan
2) �s-built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans)
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) ies 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 Town of North Andover
Catch basins
Property lines
Dwellings or other structures
Private water supply or irrigation wells JUN 17 2026
Watercourses or wetlands
8) Locations of Wells,Drains,Wetland Resource Areas within 150 feet of s,"a tth Department
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) 01- cation and holder of any easements which could impact the system
/-Impervious 13) Areas;Driveways,etc
1 4) ��Vorth Arrow
15) Location&Elevation of Benchmark used
16) /-STATEMENT ON PLAN (NA 5.3)
a. "1 certify the locations,elevations, ties,cover material;exposed component covers etc.,
shown on this as-built substantiallyagree with the approved plan and have determined that the
break out elevations,if applica ble,have been met."
Signature of Designer Date
b. "If a STCICTURAL WALL IS PRESENT(NA 4.9)a Letter or statement on the as-built indicating
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