HomeMy WebLinkAboutMiscellaneous - 665 OSGOOD STREET 4/30/2018 r
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Air Quality Experts, Inc.
(603) 894-6465 Asbestos Removal
(800) 621-1189 40 Lowell Road, Unit 1 Residential-Commercial-Industrial
(603) 894-7044 FAX Salem, NH 03079 AirQualityExperts@AQENH.com
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September 9, 2003--
SEF 0 203
North Andover Health Department
146 Main Street
North Andover, MA 01845
Dear Sir:
Enclosed please find a copy of notification sent to the state for an Asbestos
Abatement Project.
The job will take place on September 23, 2003.
Project: 665 Osgood Street
Any questions concerning this matter should be directed to my attention.
Sincerely,
Christopher Thompson
President
z
Commonwealth of Massachusetts __■
100000951
Asbestos Notification Form ANF-001 ;_-- Decal Number
Affix Asbestos
Notification Decal
Here
Important:
When filling out A. Asbestos Abatement Description
forms on the
computer,use 1. a. Is this facility fee exempt-city, town,district, municipal housing authority, owner-occupied
only the tab key residence of four units or less? ]✓ Yes [ No
to move your
cursor-do not b. Provide blanket decal number if applicable:
use the return Blanket Decal Number
key' 2. Facility Location:
DOUGLAS HOWE 665 OSGOOD STREET
a.Name of Facili b.Street Address
NORTH ANDOVER 101845 1 (978)269-22290,�& ��
o CitylTown d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this
BASEMENT
form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room
completed in order
to comply with 4. Is the facility occupied? [,]/ Yes ❑No
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and the Division
of Occupational JAIR QUALITY EXPERTS, INC. 140 LOWELL ROAD, UNIT 1
Safety(DOS) a.Nameb.Address
notification
requirements of 453 SALEM 16038946465
CMR 6.12 c.Ci !Town _. d.Zip Code e.Telephone Number
AC000167
f.DOS License Number g. Contract Type: ❑✓ Written C]Verbal
h.Facili Contact Person i.Contact Person's Title
GERMAN POSADA ZINIGA AS032579
6. a.Name of On-Site Su ervisor/Foreman b.Supervisor/Foreman DOS Certification Number
TOM SALVATELLIAM030424
7' a.Name of Project Monitor b.Project Monitor DOS Certification Number
NORTHEAST ENVIRONMENTAL LABS AA000153
_ $' a.Name of Asbestos Anal ical Lab b.Asbestos Anal ical Lab DOS Certification Number
09/23/2003 09123/2003
_0 g' a.Project Start Date(mm/dqLyyyyJ b.End Date mm/dd/ yyy
0 7AM-3PM __....._._.
N c.Work hours Mon-Fri. d.Work hours Sat-Sun.
�o 10. a.What type of project is this?
(❑ Demolition Renovation
❑ Repair Other, please specify: b.Describe
11. a. Check abatement procedures:
° ❑Glove bag El Encapsulation
o ❑ Enclosure ❑ Disposal only
ALL ❑Cleanup ❑ Other, specify:
]✓ Full containment b.Describe
--z
Q 12. Is the job being conducted: IZ Indoors? [:]Outdoors?
■ anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3■
L�e'_
Commonwealth of Massachusetts ■
100000951
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
encapsulated:
aa.Total pipesf ducts(linea b.Total other su ce square
c.Boiler,breaching,duct,tank 50
surface coatings Lin.ft. Sq.ft. d.Insulating cement Lin.ft. Sq.ft.
e.Corrugated or layered paper
pipe insulation Lin.ft. Sf.Trowel/Sprayer coatings Lin.ft. S
g.Spray-on fireproofing Li 5h.Transite board,wall board Li=
I.Cloths,woven fabrics Li� � j.Other,please specify: L..____.__
� n Lin.ft. S .ft.
k.Thermal,solid core pipe
insulation Lin.ft. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
3 CHAMBER DECON
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
WET 2 PLY POLY BAGS
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official b.Title
c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver#
e.Name of DOS Official f.DOS Official Title
g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver#
N
o 17. Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? ❑Yes[✓ No
B. Facility Description
N
0 1. Current or prior use of facility: RESIDENTIAL
�o
2. Is the facility owner-occupied residential with 4 units or less? ✓Z Yes ❑ No
DOUGLAS HOWE
3' a.Facility Owner Name _ b.Address
o C.Ci /Town — � d.Zip Code e.Telephone Number(area code and extension)
LL 4.
a.Name of Facility Owner's On-Site Manager _ b.On-Site Manager Address
M�z
�Q c.City/Town d.Zip Code e.Telephone Number(area code and extension)
■ anf001ap.doc•10/02 Asbestos Notification Form•Page 2 of 3■
r
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Commonwealth of Massachusetts
100000951
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
5. a.Name of General Contractor b.Address
c.Ci /Town d.AnCode e.Telephone Number area code and extension)
f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp_Date mm/dd/
6. What is the size of this facility? 25001 12
a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to.temporary storage site(if necessary):
SAME AS CONTRACTOR
Note:Transfer a.Name of Transporter b.Address
Stations must
comply with the c.City/Town d.Zip Code e.Telephone Number
Solid Waste
Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR 19.000 ISERVICE TRANSPORT GROUP,INC. PO BOX 2132
a.Name of Transporter b.Address
BRISTOL, PA 19007 (877)999-9559
c.Ci /Town d.An Code e.Telephone Number
3.
a.Refuse Transfer Station and Owner ( b.Address
c.Ci /Town d.Zip Code e.Telephone Number
4. JBFl IMPERIAL LANDFILL BFI IMPERIAL LANDFILL
a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
PO BOX 47-11 BOGGS ROAD JIMPERIAL
c.Final Disposal Site Address d.Ci /Town
PA 15126 (724)695-0900
e.State f.Zip Code g.Telephone Number
�O
D. Certification
N .................._.._ .,,,..� vl
The undersigned hereby states,under the CHRISTOPHER TROMPS
penalties ofperjury,that helshe has read the a.Name b.Authorized Signature
�° Commonwealth of Massachusetts regulations 1PRESIDENT J 09/09/2003
for the Removal,Containment or
,— c.Position/Title d.Date(mm/dd/yyyy)
_ Encapsulation of Asbestos,453 CMR 6.00 and 603 894-6465 (A`IR QUALITY EXPERTS
310 CMR 7.15,and that the information ( ) � I
contained in this notification is true and correct e.Tel hone Number f.Re resentin
° to the best of his/her knowledge and belief. 40 LOWELL ROAD, UNIT ONE
o Q.Address
9__LL JSALEM, NH � 03079 � �
h.City/Town I.Zip Code
Z
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anf001 ap.doc•10/02 Asbestos Notification Form•Page 3 of 3
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Date.. o-
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4 Of WORT n
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TOWN OF NORTH ANDOVER
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• PERMIT FOR GAS INSTALLATION
SAC
MUSEtt
This certifies that . . . . . .t. °... .... .
has permission for gas installation .
A,
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�in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . .
�qt . . . . .. ? . . , . . tr. , North..Andover, Mass.
Fee.C Lic. (o.. . . . . . . . . . �y�,
GASJNSPECLTORQ
Check#
4447
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
a
, Klass. Date l� , ermit # yqj
�.
Location
Building
`- S V` Owner's Name l
Type of Occupancy l e'l�I/l
New ❑ Renovation Replacement 1— Plans" Submitted: Yes ❑ No ❑
FIXTURES
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Y Z
N (A
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W Q U W Z = of
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n
y W N N Z Q C/1 W Q W !— Q
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SUB-BSMT.
BASEMENT
1st FLOOR
2nd FLOOR
3rd FLOOR
4th FLOOR
Sth FLOOR
4 6th FLOOR
l s
7th FLOOR
8th FLOOR
CLIMATE DESIGN HEATING and AIR CONDITIONING,LLC
Installing 5 South Summer Street — Check one: Certificate
Address Bradford,MA 01835 _ Corporation 7L.
978-372-9999(phone)
978-372-0882(fax) _ = Partnership
Business Telephone Lic. plumber: kA; :fir Ha Ncl-0a Aj_ = Firm/Co.
Name of Licensed Plumber or Gas Fitter
I �
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of s,iGL Ch. 142.
Yes ✓ No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity G Bond L
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.
General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
I hereby certify that all of the details and information I have submiued for entered)in the above application are true and accurate to the best of my knowledge and that all plumbing work
and installations performed under the permit issued for this application will be to compliance withal[peninent provisions of the massachusens State Gas Code and Chapter 142 of the General Laws.
H Type of License:
y =Plumber
Gasfiner
Tide feaster at a of Licens Plur r nr Gas Firer
Inurneyman
City/Town .
LiCI SC Num her 6J C V
APPROVED(OFFICE USE ONLY)
I
6 .
FINAL INSPECTIONS SKETCHES BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS
FEE
NO.
APPLICATION FOR PERMIT TO DO GASFI7TING
NAME & TYPE OF BUILDING . ..... .. .. .. ..._...._.._._._..__.__......
LOCATION OF BUILDING
PLUMBER OR GASFITTER __.._._..._..^ .'.' __..._.. ...__...-------..._
LIC. NO. _ _ — ' -- -— ----------- ..
PERMIT GRANTED
f,
Dale — ---- — 19 —--
Gas Merc.
Final Insp. -------- -----------
Gas Inspeclor
1762
APPLICATION FOR SEWER SERVICE CONNECTION
� 0
North Andover, Mass.
Application by the undersigned is hereby made to connect with the town sewer main inLrr�i' � �l Street,
subject to the rules and regulations of the Division of Public Works.
The premises are known as No. (D� / C / Street
or subdivision lot no.
go _
Owner / Address
Contractor Address
/'Applicant's Signature
p2
INS- 1
xe
ALIS.
PERMIT TO CONNECT WITH SEWER MAIN
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at Street
subject to the rules and regulations of the Division of Public Works..
Division of Public Works
By
Inspected by
Date
See back for rules and regulations
April 6,2000
Mr. Gayton Osgood, Chairman
Town of North Andover
Office of Community Development
and Services
27 Charles Street
North Andover, MA 01845
Dear Mr. Osgood:
I have received your letter regarding sewer tie-in and I would appreciate an opportunity to speak to
the Board of Health at your meeting on April 27, 2000.
Sincerely,
6(�
Douglas N. Howe
665 Osgood Street
North Andover, MA 01845
}� Town of North Andover oft 40 oT
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES °
A
27 Charles Street
• p9q «
North Andover, Massachusetts 01845
WILLIAM J. SCOTT 9SSAcwuSEt
Director
(978)688-9531 Fax (978)688-9542
March 24, 2000
Mr. &Mrs. Douglas Howe
665 Osgood Street
No. Andover, MA 01845
Re: Sewer Tie-in
Dear Mr. &Mrs. Howe:
The Health Department has been supplied with a list of all residences, currently on septic,
which have access to the municipal sewer system. As previously published at a Public
Hearing on March 17, 1994, the Board of Health has adopted regulations concerning the
required sewer tie-in. The following timetable concerning your property status was
adopted:
4.1 All establishments that currently do not have municipal sewer available
to them must connect to the sewer as soon as it becomes available, with a
maximum time limit of six months.
The purpose of these regulations is to safeguard North Andover's drinking water, surface
waters, groundwater and surrounding environment. Sanitary sewer is believed to be the
most effective form of wastewater treatment. A copy of the entire regulation can be
obtained at our office.
Your property is in violation of this Board of Health regulation. Please contact the Health
Department regarding this matter immediately. If we do not hear from you by May 10,
2000 your name will be placed on the regularly scheduled Board of Health meeting agenda
and placed on public notice. The meeting will be held on May 25, 2000 for discussion of
legal action including court hearings.
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
i
i
�J Sewer Tie-In 665 Osgood Street Page
Any questions concerning this regulation should be directed to the Board of Health at
(978) 688-9540. Additional inquiries regarding the physical tie-in and permitting process
should be directed to the Department of Public Works at (978) 685-0950. Please be
advised this Board intends to persevere in this regulation.
Yours truly,
G yton Osgood, Chairman
c� ��V
Francis P. Mac
M
illan, M.D., Member
S. Rizza, D.M.D., e er
SF/smc
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
I
Date of Pumping: (c) -- om Quantity Pumped: Cnj- gallons
Cesspool: No Yes [I Septic Tank: No [] Yes [-I-----
System Pumped by: 04&a" License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
i
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JaN i 1 2TO
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\an �v� r�p1, (` 3 � � ��` � �^� EiGHT IiLTON STFlr_ET
�� !! aJ7 u 9 METHUEN. MASSACHL,-SEYTS Oli=44
n C• (617) 68i_.,826
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t i� L J-14/1,J. 3, 9 7 9
a,ul rlic,-��cn�ors ---
T 0 . NORTH r1ii DOV �R H ,ziL1,11-
1'C:Vi. i;LL , i+O. Ii'aiiOVl;ti
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SUBSURFACE" J1�.J y�i _)I )PC,J �I D_YST .1v.
OSGaOC� 5%�G-�T N0. AI`; �OVLR
I hereby certify that I have inspected the construction of the
disposal system at &65 0<5,,,-c7oy <57-eG29north Andover, I,'.ass .
and. that the location and elevations are as shown on the As-Built
Drawing dated --T,47.1. 2, i976
ANDOVER CCP;:_SULTANTa IidC.
illia n S'-- . ,:acLeod
Registered Sanitarian
This C-__�-____T_-0`1_—_iOt O 1`e co.-istr ed z a F 1. rantee of the sys'
vE,e FL E IIA T/ONs
T.2AP /NCE T - 94.85
TCAP 0117-ZET 9¢29
TANK IAIZ ET
TAA/.0 OUTLET 92.82
3¢' ,BOX /NLE-T- 92.37
BOX OUTLET 92.2 "
EX1ST/ll/G 102-7-A" INLEr 9-1¢7
DWELL//VG PI� B�INLET -- -- -8�53
PIT B OlJTL ET 87lS
30'
O' B.iYf. TOP OF
F/PST 3TEEX T.
Ol� � � ESE✓ /00.000 /S
X21 �ASSUMED� T2APE
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Iq Qs -0,-,//&7- Z),,--4 vv/n/G
1� 0� cJU8SU2FACE cSEWA!aE 2,DISPOSAL SYSTEM
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EX/ST. � c.S�CALE � I"`ZO DATE TAAl. /97S
SEPTIC Owive: AzrHurz ,T 6ONYA
TANK
LOCATION: 4665 0S600D ST.
�- IVo27-1-1 ANDOVER I AJASS,
A � �
SEEPAGE
andover or
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B
\ COnSUltantS wI is
OI/EKFLOw P/PE- TO inc. I M CLEOD U
NO.742
EX/S T/vG ABS02PT/o t/ BED 9a q p p/t
F FrISTU,
8 Tilton Street,Methuen , Mass. fSSi�v L S,\,
Tel. 687-3828
7-/-//-- DRAW/NU , W/TN ATTACAED CE2T/F/CAT/DN
/'5 O .4SA//OT GUARANTEE
71-1,47- THE SYSTEM W/GL FUNCT/ON P20PERL
m
0 1
206 ANDOVER ST., SUITE 11 Mp�
ANDOVER, MA 01810 :.. ;
(508) 475-1237
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address: 665 Osgood Street, North Andover, MA
Address of Owner (if different): N/A
Name of Inspector: Peter F. Reilly
Company Name, Address, Phone #: F.P. Reilly & Sons, 206 Andover St., Suite 11
Andover, MA 01810 (508) 475-1237 / (508) 475-4370
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on-site sewage disposal systems. The system:
✓ Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
0
Inspector's Signature: Date: 5/3/97
Peter F. Reilly
The system inspector shall submit a copy of this inspection report to the approving authority within thirty (30) days
of completing this inspection. If the system is a shared system of has a design flow of 10,000 gpd or greater, the
inspector and the system owner shall submit the report to the regional office of the Department of Environmental
Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the
approving authority.
INSPECTION SUMMARY:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that the system violates any of the failure criteria as defined
in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
— SERVING ANDOVER & VICINITY FOR OVER 40 YEARS —
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 665 Osgood Street, North Andover, MA
Owner's Name: Arthur Gonya
Date of Inspection: 5/3/97
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the replacement or
repair, passes inspection.
Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined", explain
why not)
N The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
N Sewage backup or breakout or static high water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
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 is failing
to protect the public health, safety and environment.
1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT
PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or
tributary to a surface water supply.
N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well.
N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a private
water supply well, unless a water well water analysis 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 than 5 ppm.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 665 Osgood Street, North Andover, MA
Owner's Name: Arthur Gonya
Date of Inspection: 5/3/97
D. SYSTEM FAILS:
N/A I have determined that the system violates one or more of the following failure criteria as defined in 310
CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N/A Liquid depth in cesspool <6" below invert or available volume <1/2 day flow.
N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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. If the well has been analyzed to be acceptable, attach copy of well
water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above.
N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
N The system is within 400 feet of a surface drinking water supply
N The system is within 200 feet of a tributary to a surface drinking water supply
N The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone 1I of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment
program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the DEP for further information.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 665 Osgood Street, North Andover, MA
Owner's Name Arthur Gonya
Date of Inspection 5/3/97
Check if the following have been done:
✓ Pumping information was requested of the owner, occupant and Board of Health.
✓ None of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system
recently or as part of this inspection.
✓ As built plans have been obtained and examined. Note they are not available with N/A.
✓ The facility or dwelling was inspected for signs of breakout.
✓ All system components, excluding the SAS, have been located on the site.
✓ The septic tank manholes were uncovered, opened and the interior of the septic tank was inspected for
condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of
scum.
✓ The size and location of the SAS on the site has been determined based on existing information or
approximated by non-intrusive methods.
✓ The facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of SSDS.
PART C - SYSTEM INFORMATION
FLOW CONDITIONS
j RESIDENTIAL:
I
Design Flow: 550 gallons
Number of bedrooms: 5
Current residents: 2
Garbage grinder: yes
Laundry connected to system: yes (overflow only)
Seasonal use: no
Water meter readings, if available: about 40,000 cu.ft. last two years
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
i
Type of Establishment: N/A
Design Flow: N/A
Grease trap present: N/A
Industrial waste holding tank N/A
Non-sanitary waste discharged
the Title 5 system N/A
Water meter readings, if available: N/A
Last date of occupancy: N/A
OTHER:
Describe: N/A
Last date of occupancy: N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 665 Osgood Street, North Andover, MA
Owner's Name Arthur Gonya
Date of Inspection 5/3/97
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: about two years according to owner
System pumped as part of inspection: yes
if yes, volume pumped: 1,000 gallons
Reason for pumping: maintenance
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no - if yes, attach previous inspection records, if any)
Other (explain)
APPROXIlVIATE AGE of all components, date installed (if known) and source of information:
Original system installed when house was constructed in 1938. Replacement system installed in 1978. "As
built" plans were available and accurate.
Sewage odors detected when arriving at the site NO
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 8"-12" (to chimney risers)
material of construction: ✓ concrete metal FRP other (explain)
Dimensions: rectangular - 1,000 gallons (dual chamber)
3" sludge depth
28" distance from top of sludge to bottom of outlet tee or baffle
1" scum thickness
N/A distance from top of scum to top of outlet tee or baffle
6" distance from bottom of scum to bottom of outlet tee or baffle
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation
to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
Tank appeared structurally sound and functioning properly. Baffle consisted of a 90 degree elbow extending six (6)
to seven (7) inches into tank.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
GENERAL INFORMATION (continued)
Property Address: 665 Osgood Street, North Andover, MA
Owner's Name Arthur Gonya
Date of Inspection 5/3/97
GREASE TRAP: ✓ (locate on site plan)
Depth below grade: manhole cover at surface
material of construction: concrete metal FRP other (explain)
Dimensions: cylindrical - less than 100 gallons capacity
1" scum thickness
N/A distance from top of scum to top of outlet tee or baffle
N/A distance from bottom of scum to bottom of outlet tee or baffle
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet
invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
Grease trap was part of original system, was left intact at time of system replacement in 1978. Collects solids from kitchen and
washing machine, overflow carries liquids to septic tank. Was pumped and cleaned during inspection.
TIGHT OR HOLDING TANK: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions:
Capacity: gallons per day
Design Flow: gallons per day
Alarm level:
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,
recommendation for repairs, etc.)
Two lines leaving d-box. No evidence of run back or solids carryover. Box was about 30" below grade and appeared structurally
sound.
PUMP CHAMBER: N/A (locate on site plan)
N/A pumps in working order, yes or no
Continents: (note condition of pump chamber,condition of pumps and appurtenances,recommendations for maintenance or repairs,
etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
GENERAL INFORMATION (continued)
Property Address: 665 Osgood Street, North Andover, MA
Owner's Name Arthur Gonya
Date of Inspection 5/3/97
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain: not applicable__
Type
leaching pits and number two pits as per "as-built" plan. no standing water observed
leaching chambers and number N/A
leaching galleries and number N/A
leaching trenches, number, length N/A
leaching fields, number, dimensions N/A
overflow cesspool, number N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance, repairs, etc.)
No hydraulic failure, no ponding or vegetation over leaching area.
CESSPOOLS: N/A (locate on site plan)
number and configuration N/A
depth-top of liquid to inlet invert N/A
depth of solids layer N/A
depth of scum layer N/A
dimensions of cesspool N/A
materials of construction N/A
indication of groundwater inflow (cesspool
must be pumped as part of inspection) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
materials of construction N/A
dimensions N/A
depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
GENERAL INFORMATION (continued)
Property Address: 665 Osgood Street, North Andover, MA
Owner's Name Arthur Gonya
Date of Inspection 5/3/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate all wells within 100' N/A
SEE ATTACHED "AS-BUILT " PLAN
SEPTIC TANK TIES: B to Inlet (I) N/A C to Inlet N/A
B to Center (C) N/A C to Center N/A
B to Outlet (0) N/A C to Outlet N/A
D-BOX TIES: A to Box N/A B to Box N/A
NOTE: System is in the side yard, near the northerly lot line.
DEPTH TO GROUNDWATER
>4' depth to groundwater (below bottom of SAS)
method of determination or approximation:
Severe grade changes and soils indicate no groundwater problems.
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PATRICK J. DONOVAN ASSOCIATES, INC.
"CLAIM AND LOSS ADJUSTMENTS"
P. O. Box 110
Wakefield, MA 01880
F1LE (617) 245-5540
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS. CHP. 139, SEC. 3B
TO: Building Commissioner or
Inspector of Buildings
City or Town Hall a
North Andover, MA 01810
RE: Insured: Arthur Gonva
Property Address: 6-65- Osgood-Street;
North Andover, MA 01810
Policy Number: 1586076
Loss Type: Ice Snow
Date of Loss: 1/29/94
Our File Number: WAP 18825
Claim has been made involving loss, damage or destruction of the above-
captioned property, which may either exceed $1, 000 or cause Mass. Gen. Laws,
Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen.
Laws, Chapter 139, Section 3B is appropriate, please direct it to the
attention of the writer and include a reference to the captioned Insured,
location, policy number, date of loss and file number.
Stephen J. Daglio, Adjuster
Donovan Associates, Inc.
Wakefield, MA 01880
On this date, I caused copies of this notice to be sent to the persons named
above at the addresses indicated above by first class mail .
June 4, 1994
Contt1ionw alth of Massachusetts
4�&,6Y-Massachusctts
System Pumping Record
System Owiter System Location
140 vi �� O
Date of Pumping: �— Quantity Pumped: l�X-t/gallons
Cesspool: No Yes Septic Tank: No Yes �-�---�
Systein Pumped by: Felredoff 5(04 th4 deQ License#
Contents transferrred to : Greater Lawrence Sanitary District
hate: Inspector:
n i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: —
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
,� , (example: left front of house)
DATE OF PUMPING: 4-0 1
QUANTITY PUMPED ( ® 'GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: