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HomeMy WebLinkAboutTitle V Inspection Report - 190 MILL ROAD 9/18/2003 �. �.�...o. _ _......_ .... ,.. ....�.�.�..�. ....... . ..... ...... .. . ............ .._...... NEW ENGLAND ENGINEERING SERVICES e6 4 N September 19, 2003 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 190 Mill Road,North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osgog 60 BNW' (":HWC'1OD DIME -NUORT14 ANDOVER,, A 0184 -(978)686-1-768-(888)359-7645- FAX(978)685-1099 a3 - 7b COMMONVYEALTH OF MASSACIIUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE S OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 190 A41 u.c, gD 42p ru-Y Ati>c)y6 Owner's Name: S0jjV.ELt4, l. O-Wc(T Owner's Address: lqo 4�- 20 2 a o✓d-K Date of Inspection: 909 . Name of Inspector:(please print)-Beni amin C. Osgood, Jr. Company Name:New England Engineering Services Inc. MaHingAddress:60 Beechwood Driye, North Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,ac=ate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15 340 of Title S(310 CMR 15.000 The system:, ✓ asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Ins&etotr's Signature: Ditto: c I o' Tho system inspector shall submit a copy of this ins ion report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design:flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate ragional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: t CeQ M i c4- R� Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. System Passes: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. a system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or no determined(Y,N,ND)in the for the following statements.If' determined'please " explain. • The septic tank is m wand over 20 years old*or the septic tank(wheth etat or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is' ' ent.System will pass inspection if the existing tank is replaced with a co plying septic tank as approved by the oard of Health. A metal septic tank will pass inspedtion if it is structurally sound,no Baking and if a Certificate of Compliance indicating that the tank is less than 20 s old is available. ND explain: Observation of sewage backup or break o high static water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled o no distribution box.System will pass inspection if(with approval of Board of Health): b en pipe(s)are r aced obstruction is remov distribution box is level or replaced ND explZqys tem required pumping more than 4 tunes a year due to b ken or obstructed pipe(s).The system will- pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:190 {�oh%b Owner: gu2(ZELt_ C-0- Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system i iling to protect public health,safety or the environment. I. stem wilt pass unless Board of Health determines in accordance with 310 CMR 15,303 b)that the sys m is not functioning In a manner which will protect public health,safety and the a 'ronment: 1 or privy is within 50 feet of a surface water Cesspo or privy is within 50 feet of a bordering vegetated wetland or a salt 2. System will fail unless the rd of Health(and Public Wat Supplier,if any)determines that the system is functioning Ina manner at protects the public h 11h,safety and environment: , _ The system has a septic tank an . it absorption tem(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a sur ce water apply. The system has a septic tank and SAS• e SAS is within a Zone 1 of a public water supply. The system h/orgame nk - d SAS and the S is within 50 feet of a private water supply well. The system hand SAS and the SAS is than 100 feet but 50 feet or more from a private water suppethod used to determine dista **This system pa if ll water analysis,performed at a D certified laboratory,for colifoM bacteria and vola mpounds indicates that the well is fir om pollution from that facility and the presence qVhmmonia nitrogen and nitrate nitrogen is equal to or 1 an 5 ppm,provided that no other failure Grit la are triggered.A copy ofthe analysis must be attached to orm. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address;_ 140 vi-t— ROA-V� AVo 2-at /QA)(3&j&i 2 Owner: 501Z W Lc,wts 9-1 Date of Inspection:— Et 0 3_ D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No _k, Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or -clogged SAS or cesspool t,- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pip*).Number of times pumped : Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well.- Any portion of a cesspool or privy is within 50 feet of private water supply well, . v Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes K the well water analysis, performed at it DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less tUan S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (VwMo)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 100000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The foal ing criteria apply to large systems in addition to the criteria above) Yes no the system is wi&1c'r4 0 fact of a surface drinking w ter'supply the tam is within 200 feet o bu o a surface drinking ater supply g pp Y the system is located in a9tr gen sensih a=thesyste Wellhead Protection Area—IWPA)or a mapped Zone 11 o="yoe'to te supply well If you have ans er n aestion in Sec tio considered a si ificant threa or answered Y � Y q � €#h � "yes"in S t on D above the large system has failed.Tl�e owner or ope at�r of any largo system considered a si�nifiSant threat under Section L�or failed under Section D shall upgrade th--s tam in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the De artmcnt. Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Mc sAm L t... iZS) _ Nall Cit A,0DoufA- Ownert Ou(Z 0.V Date of Inspection: < o Check if the follow have been done.You must indicate'yes"or`Sno"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health ere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? +"Have large volumes of water been introduced to the system recently or as part of this inspection? _ V Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size avid location of the Solt Absorption System(SAS)on the site has been determined based on- Yes Ao Existing information.For example,a plan at the Board of Health. -ZWernnined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15,302(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: !!Zo 2o#+o Owner: i XLzG-(_L awG(L� Date of Inspection: ed0 FLOW CONDITIONS RESIDRNTIAL Number of bedrooms(design): -- Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110 gpd X#of bedrooms): Number of current residents: .3 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no);,t C (if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no). Water meter readings,if availablo(last 2 years usage(gpd)): Sump pump(yes or no): c� Last date of occupy: C-0 t ee.✓t i COMMERCtAUMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_ Qnd Basis of design flow(seats/personstsgft,etc.): Orease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last dato of occupancy/use, OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: c-e ,m A�l P&-rz. Ow.ui= Was system pumped as part of the inspection(yes or no):" If yes,volume pumped: _gallons--How was quantity pumped determined? Reason-for pumping: TYPE OF SYSTEM _y_.Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _InnovativelAlternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank Attach a copy of the DEP approval Other(describe): - - Approxi nV age of all components,date installed(if known)and source of information: 'j� ty0 PER ©w.y C P_ Were sewage odors detected when arriving at the site(yes or no):A Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t as tit zu�- jLt�,4D L2o&1)4- /k�s r>yi12 Owner: �3� g rw ►_a w G R`( Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 4©PVC other(explain): Distance from private water supply well or suction fine: Comments(on condition of joints,venting,evidence of leakage,etc): SEPTIC TANK:_(locate on site plan) Depth below grade; 10, Material of construction: ncxete metal fiberglass_polyethylene other(explain) if tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no); (attach a copy of certificate) Dimensions: /oar lsfj 1- - o.�S Sludge depth: ' Distance from top of sludge to bottom of outlet tee or baffie: 33 f Scum thickness, < " Distance from top of scum to top of outlet tee or baffle: 11 'Distance from bottom of scum to bottom of outlet tee or baffie: 2.2'' How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc:): Td'o tN 6-0 GREASP TRAPrLi"ocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tea or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page g of It OFFICIAL INSPECTION FORM"NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6670 .ca r c.a.. J10( Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass olyethylene othet(explain): Dimensions: Capacity: ealions Design Flow• gallonslday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc): DIMMUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): gV4 !rd 01A, GONritilOA, i��ar�`,b , niD �Jt �r«ue n!� LL=1�lCikCr(� A(L SJt.I 1R�OJG _Cyt�CZ C &19-cm !;p 5�P Pc c�r44&,V7��j c ►i?r Ia��+"��1�, _)r PUMP CHA.MBEI<tVO+ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc): Pagc 9 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ., Properly Address: I CIO ,41 LL iQn "I'loijU7e AA_)Douy ,-,k4 Owner: o v e:.L- Date of Inspection: 6j,-)3 8011 ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: _leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: r.�,../leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): FI62 .0 A-1 �a2n�.4r A ��clsP c U si�3rl�� �?c�2rrier� o_ 1^-, ©E> e" R>/--c tip sTn 'Ne­ OX&6,eUc;A s a« �,s5 auk S 't CESSPOOL& NA cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulio failure,level of ponding,condition of vegetation,etc.): PRIVY:M(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /-Icy Owner: S u tc a&L-L 1�a w c Ry Date of Inspection;_ G-li E2/g SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet,Locate where public water supply enters the building. ,3'A6` Page It of 11 OFFICIAL INSPECTION FORM"NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Igo m el=i- 2o4s) 620 t.lx A&a.2,o�,&k ,4 Owner: 0 0 A22 C-L-tr 1- ,o W C' xu Date of Inspection: t al C� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water t_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system ddsign plans on record-if checked,date of ddsign plan reviewed- Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain- Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation- 13 0 1-1b e%A �F s4/s3CM 7 .je- F NORTI- ANDOVER _ SYSTEM PUkPINC RRCORD 9� �► � 1)•3•rrs;' 6 ao f r51's`T9M OWNRR & ADDRESS �. SYSTEM LOCATION . / (example: left fro t of house) e�.�o �j-'cam �dYnP/1 `90 1�• / G'�.� vA'I'E OF PUMPING: —LQ -d G'� .L � �,T 3I t;N'SS1100L., NO YE3 SEPTIC TANK: NO YES 0 NATURi'OF SLRYICI£; ROUTM9 EMERCENCY t 0seRVATIONS; • 6/ • COOD CONDITION FULL TO COYr(t HRAVY ORRA32 -BAFFLES IN PLACE' ROOTS LEACHFIRLD RUNBACK, CXCESSIkE SQLlDS FLOODED SOLIDS CARRYOVER�. jpprm (EXPLAJN) 5t•a•I UM PUMPS ? BY: c.'oVvI rNTS: . c U�'•I't;N'I'�' IwANSREItR20 TO., , DECATAM 50 CONCORD STREET, NORTH READING, MASSACHUSETTS 01884 "�V1tPi OF NORTH AIVgtJ`.' 41/ 978.470.2860 BOARD OF HEALTH { FAX 978-470-1017 r ,IAN Z 7 2004 January 26, 2004 r t. Health Department Town of North Andover 27 Charles Street North Andover,- 01845 RE: Asbestos Abate ent 190 Mill Road Dear Sir-or-lViadam: Please be advised that Dec-Tam Corporation will be performing an asbestos abatement project at the above referenced location. This work has been scheduled for February 9, 2004. All applicable local, state and federal agencies have been notified of this work. Please let me know if you have any questions. Sincerest regards, Brenton D, rgenstern Sales Estimator BDNVjmp Enclosure A ASBESTOS ABATEMENT A MOLD REMEDIATION A LEAD ABATEMENT www.deotam.00m E-mail: solutions @dectam.com Commonwealth of Massachusetts E770782 Please Enter Decal# ............... Asbestos Notification Form AN -001 NQ 770782 A. Asbestos Abatement Description Important: When filling out 1. Facility Location: forms the Ms Catherine Lowe 190 Mill Road computeto r,use Lowery only the tab key Name of Facility Street Address to move your North Andover Ma 01845 978-682-8165 cursor-do not Cltyfrown State Zip Code Telephone use the return. key' Worksite Location: Basement Building name,#,wing,floor,room. 2. Is the facility occupied? ®Yes ❑ No 3. Asbestos Contractor: Dec-Tam Corporation 50 Concord St Name Address INSTRUCTIONS N. Reading. MA 01864 978-470.2860 1.All sections of Cityfrown Zip Code Telephone this form must be AC000035 Contract Type: ®Written ❑Verbal completed in order DOS License# to comply with Brenton D. Morgenstern Sales Estimator DEP notification Facillty Contact Person Contact person's title requirements of 310 CMR 7.16 Charles Brewer ASB30534 and the Division 4. Name of On-Site Supervisor/Foreman DOS Certification# of Occupational S afety(DOS) 5, FLI Environmental AA000144 Safety Name of Project Monitor DOS Certification# requirements of FLI Environmental AA000144 453 CMR 6.12 6. Name of Asbestos Analytical Lab DOS Certification# 2.Submit Original Form to: Commonwealth of 2/9/04 2/9/04 Massachusetts 7. Project Start Date End Date Asbestos Program PO Box 120087 Boston MA 02112-0087 7am-4pm NA Work hours Mon-Fri. Work hours Sat-Sun. 8. What type of project is this? ❑ Demolition ® Renovation ❑ Repair ❑ Other, please specify: 9. Check abatement procedures: ❑ Glove bag ❑ Encapsulation ❑ Enclosure ❑ Disposal only ❑ Cleanup ® Other,specify: CriticalBarder/Neg Air/Poly Wails/Deconl ❑ Full containment Remove floor tile/2xbag 6-mil poly 10. is the job being conducted: ® indoors? ❑ Outdoors? . 04010046 LoweryNoAndoverMa•9/02 Asbestos Notification Form•Page 1 of 4 Commonwealth of Massachusetts E770782 Please Enter Decal# Asbestos Notification Form AN -001 B. Facility Description (cont.) 5 n/a Name of General Contractor Address Citylrown Zip Code Telephone Commerce& Industry WC9694329 12/28/04 Contractor's Worker's Comp.Insurer Policy# Exp.Date 6. What is the size of this facility? 2700 2 Square Feet #of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site (if necessary)to final disposal site: Service Transportation Group 58 Pyles Lane Note:Transfer Name of transporter Address Stations must New Castle, DE - 19720 302-778-5930 comply with the City/Town Zip Code Telephone Solid Waste Division 2, Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 As Above Name of transporter Address City/Town Zip Code Telephone 3. Refuse transfer station and owner Address City/Town Zip Code Telephone 4. Minerva Landfill n1a Final Disposal Site'location name Owner's Name 9000 Minerva Road Waynesburg Address City/Town OH 44688 330.886-3435 State Zip Code Telephone D. Certification The undersigned hereby states, under the Brenton Morgenstern penalties of perjury,that he/she has read Name Authorized Sl ature and Date the Commonwealth of Massachusetts Sales Estimator Dec-Tam Note:Contractor regulations for the Removal, Containment must sign this form or Encapsulation of Asbestos,453 CMR Positionfritle Representing for Dos notification 6.00 and 310 CMR 7.15,and that the 978-470-2860 50 Concord St purposes information contained In this notification is Telephone Address true and correct to the best of his/her N. Reading,MA 01864 knowledge and belief. Cltyffown Zip Code Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or Less?) ®Yes [a No 04010046 LoweryNoAndoverMa•9/02 Asbestos Notification Form•Page 3 of 4