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HomeMy WebLinkAboutCertificate of Compliance - 440 BOSTON STREET 11/24/2015 • ���'fI;ED�69�, • • PUBLIC BLIC HL'AL 1 H DEPARTMENT Town of Forth Andover Community Development Division CERTIFICATE COMPLIANCE As of: 11/24/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of an On-Site Sewage Disposal System By: Chad Jablonzki At: 440 Boston Street Map 107D Lot 3 North , MA 01845 The'l.s ance this certific to s a 1 n�©t �-, construed as a guarantee that the system will function satisfactorily. Qj `~ Mi' bete Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.coni l i i i t PUBLIC:HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER SEP'T'IC DISPOSAL SYSTEM —INSTALLATION CERTIFICATIO The undersigned hereby certify that the Sewage Disposal System(constructed;( )repaired; By: (Print Name) HLocated at: ` 4 '- (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated 5e 'Z(�11()1 Sand last revised on 0 6-f � � 0 1 with a design flow of ? ;� 3 0 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,'I'itle 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: I/) 0 V 0 t S _ Engineer Representative(Signature) And-Print Name j v)1'>-0- 6t KI)0 2- S ",i� Final Construction Tnspec ion 1 Date: ��'' �~ i 2-0 1 Engineer Representative(Signature) And-Print Name .. _ ... . . Installer: (Signature) Date: +� And-Print Name Engineer: t✓(Signature) Date: )00 2- 9 , 2_01S And-Print Name 1 ood Street, North Andover, Massachusetts 01845 hone 978.688.9540 Fox 978«688«8476 Wei) http://www.townofnorthandover.com i Town of North Andover — Septic System 1) V All changes to the design plan have been reflected and noted on the as-built plan 2) _L--"'As-built plan has a suitable scale; (1 inch= 40 feet or fewer for plot plans) 3) JzStreet Address,Assessor's Map and Lot Number 4) 4ZLot Lines and Location of Dwellings served by the system 5) V 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 etback distances are shown on the as-built plan from system components to: Subsurface,interceptor&foundation drains JACatch basins !/Property lines Dwellings or other structures IM�P vate water supply or irrigation wells watercourses or wetlands 8) I- Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system 9) Location of water,gas,electric lines,cable,control panel (if applicable) 10) Vocation of Structures within 6 Inches of Finished Grade 11) _ riginal Stamp&Signature 12) V Location and holder of any easements which could impact the system 13) V Impervious Areas;Driveways,etc 14) North Arrow 15) Location&Elevation of Benchmark used 16) STATEMENT ON PLAN (NA 5.3) a. _ it "I eert(y the locations, elevations, ties, cover fnaterlal;exposed component covets etc., shown on this as-built substantiallyagree with the apps-oved plan and ha ve determined that the bf eak out elevations,if applicable,ha ve been met." /0V .-,) H , 20 IS Si ture of Desig r Date b. "Ifa STUCTURAL WALL IS PRESENT(NA 4.9)a Letter or statement on the as-built indicating the wall- was,or was not, constructed in accolrtance with the intended design and an v manufactulvr's sr�ecif cations." Signature of Designer Date As of:Tuesday,March 17,2015 Town of North Andover — Septic System a AS-BUILT CHECKLIST i 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; (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) 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 aCatch basins Property lines j Dwellings or other structures Private water supply or irrigation wells -I "Watercourses or wetlands 8) Locations of Wells,Drains,Wetland Resource Areas within 150 feet of system 9) ° Location of water,gas,electric lines,cable,control panel (if applicable) 10) Location of Structures within 6 Inches of Finished Grade 11 TOOrigmal Stamp &Signature 12) Lcation and holder of any easements which could impact the system 13) hnpervious Areas;Driveways,etc 14) North Arrow 15) Location&Elevation of Benchmark used 16) STATEMENT ON PLAN (NA 5.3) a. "I certify the locations, elevations, ties, cover material;exposed com onent covers etc., shown on this as-builtsubstantiallyagree with the approvedplan and have determined that the breakout elevations,ifapplicable,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 indicating the wall- was, or was not,constructed in accol dance with the intended design and any manufacturer's specifications." Signature of Designer Date As of:Tuesday,November 24,2015