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Home My WebLink AboutMiscellaneous - 754 BOXFORD STREET 4/30/2018 (2)J Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rah Commonwealth of Massachusetts Title 5 Official Inspection F o Subsurface Sewage Disposal System Form - Not,fj- 754 Boxford Street ((,, Property Address Dave Hart 7 Owner's Name North Andover _ Ma 01 Citylfown State Zip Code a' ant�� 1/24/17 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: John DiVincenzo Name of Inspector J and S Development Corp / Stewarts Septic Service M, Company Name 58 South Kimball St Company Address Bradford Cityfrown 978-372-7471 Telephone Number B. Certification MA State s113386 License Number 01835 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate 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 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Signature Date T� system inspector shall submit a copy of this inspection report to the Approving Authority (Board o Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional 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. '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. t5ins.doc - rev. 6116 Title 5 Offcial Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 ,—A Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner's Name North Andover Ma 01845 _ 1/24/17 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I 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: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc • rev, 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover required for every page. Cityrrown B. Certification (cont.) Ma 01845 State Zip Code 1/24117 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box is coroaded around the outlet. Invert needs replacing. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc - rev. 6116 Ttle 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner's Name North Andover Ma 01845 City/Town State Zip Code B. Certification (cont.) 1/24/17 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® 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 ❑ ® 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 Y2 day flow t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 754 Boxford Street Property Address Dave Hart Owner Owner's Name nform quine d fotifo is every on equireNorth Andover Ma 01845 1/24/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No E]® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El® Any portion of the SAS, cesspool or privy is below high ground water elevation. E]® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El® Any portion of a cesspool or privy is within a Zone 1 of a public well. El® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El® 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 if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] i re ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc • rev. 6116 Ttle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M yV•y,'� 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover Ma 01845 1/24/17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were 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? Were as built plans of the system obtained and examined? (If they were not available note as N/A) 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 and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 gpd t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. CityfFown D. System Information Description: Number of current residents: Ma 01845 State Zip Code 1/24/17 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No ❑ Yes ® No occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Ma 01845 1/24117 State Zip Code Date of Inspection General Information Date Source of information: Stewart's Septic Service Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site guage on truck Reason for pumping: Inspect tank Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Property Address Dave Hart Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Ma 01845 1/24117 State Zip Code Date of Inspection General Information Date Source of information: Stewart's Septic Service Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site guage on truck Reason for pumping: Inspect tank Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. Cityrrown Ma 01845 1/24/17 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 38 vears Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 22"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 10" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. Cityrrown t5ins.doc - rev. 6N6 D. System Information (cont.) Ma 01845 State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 30" 1" 5" 15" 1124117 Date of Inspection How were dimensions determined? Tape measure sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles are good. No leakage and the liquid level is good. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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 tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. City/Town Ma 01845 State Zip Code 1124117 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Desi n Flow g gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5irs.doc • rev. 6/16 Title 5 Official Inspectcn Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. Cityfrown D. System Information (cont.) Ma 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): 1/24/17 Date of Inspection 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.): Distribution box needs replacing. Very little solids carry over. Leakage around outlet inverts. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc • rev. 6/16 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Type: Ma 01845 State Zip Code 1124/17 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 1-20x45 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding and there are no damp soils. Cesspools (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 ❑ No t5irs.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is North Andover required for every page. Citylrown Ma 01845 state Zip Code 1/24/17 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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. ): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner's Name North Andover Ma 01845 1/24/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Vis` 1 [3oxt!o>� AST..... . ... r . Into J .......................................... C _ ..................... . ..... , .. ........... ;....a` . ............................. L.....................':. i 1 .... .�.,.. .,f....... / ......:......... .. ._.... . 8..... _......._ [.l.'..a.....� ...... .tom .,..,.�.C2.s ._. .......... Wilmington Plant Amesbury Plant Rochester Plant Mottingham Plant 773 Salem St Wilmington, MA 87 Haverhill Rd Amesbury, MA 153 Cranberry Hwy Rochester, MA 160 Old Turnpike Rd Nottingham, NH 01887 01913 (978) 658-2645 (978)388-1509 02770 (508) 291-1314 03290 (603) 942-5668 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. CityFrown D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Ma 01845 State Zip Code 1/24/17 Date of Inspection Estimated depth to high ground water: S-6" feet Please indicate all methods used to determine the high ground water elevation: /1 10r, Obtained from system design plans on record If checked date of design plan reviewed' 3-26-77 ' Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Pulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Taken from design plans on record. S.H.W.T at elevation 93.5 Bottom of the bed 97.5 System 4' above the water table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insAoc • rev. 3116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover Ma 01845 page. City/7own State Zip Code E. Report Completeness Checklist 1/24/17 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 2-7-2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -box and 2 Pipes By: John DiVincenzo At: 754 Boxford Street Map 105.A Lot 0018 North Andover, MA 01845 of this geNfiga&all not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com SEPTICsu tems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ATitle 5Inspector $50- 0 50❑ Title 5 Report $ ❑ Other. (Indicate) $ Hea Agent Initials White - Applicant Yellow - Health Pink - Treasurer 7761 f 9 Town of North Andover HEALTH DEPARTMENT 'ss4CNU5E� CHECK #: 159"0 DATE: LOCATION: %Sy 13 oy- GV .5'6 �H/O NAME: ,�a.✓e, �,��r CONTRACTOR NAME: Z-okn 6; VlocoiG Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTICsu tems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ATitle 5Inspector $50- 0 50❑ Title 5 Report $ ❑ Other. (Indicate) $ Hea Agent Initials White - Applicant Yellow - Health Pink - Treasurer t, a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessme G0/ D 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover Ma 01845 1/24/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. 0 IV -In Important: When A. General Information ��G filling out r on the computer, use only the tab 1. Inspector: �R key to move your p1D0 cursor - do not John DiVincenzo pFN�R�NtZZME use the return Name of Inspector L key. N� J and S Development Corp ! Stewarts Septic Service VILA Company Name 58 South Kimball St Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 s113386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate 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 5 (310 CMR 15.000). The system: ® Passes ❑ lIeeds,F ❑ Conditionally Passes ❑ Fails Evaluation by the Local Approving Authority Date The system inspdctoAall submit a copy of this inspection report to the Approving Authority (Board of Health or D P hin 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional 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. """"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. t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 754 Boxford Street Property Address Dave Hart Owner Owner's Name information is required for every North Andover page. Citylrown t5ins.doc • rev. 6116 B. Certification (cont.) Ma State n1Ad5 up vuuc R 1/24/17 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I 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: The distribution box was B) System Conditionally Passes: on 2-6-17 ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES D - Box 2/7/2017 LOCATION INFORMATION ADDRESS: 754 Boxford Street MAP: 105.A LOT: 0018 INSTALLER: Stewarts Septic Service DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ® Installed on stable stone base ® H-20 D -Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: Michele Grant did inspection. It looks like an outlet pipe maybe crushed. Asked them to expose the pipe. In fact there are 2 crushed pipes. Replaced the pipes with schedule 40. Ok = reinspection SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN 4 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 10' ❑ Private drinking well 75 1001 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Commonwealth of Massachusetts Map -Block -Lot 105.A0018 BOARD OF HEALTH Permit No North Andover BHP -2017-0324 --------------- -- P•I• FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted ------------------------------------------------------- ------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. at No 754 BOXFORD STREET as shown on the application for Disposal Works Construction Permit No. BHP -20177032 Dated February -06,-2017 d _ L. j Issued On: Feb -06-2017 ---------------------------------------------------------------------------------- BOARD OF HEALTH 0 Commonwealth of Massachusetts Map -Block -Lot 105.A0018 ----------------------- BOARD OF HEALTH permit No North Andover - BHP -2017-0324 ---------------------- P.I. FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted to (Construct) an Individual Sewage Disposal System. at No 754 BOXFORD STREET as shown on the application for Disposal Works Construction Permit No. BHP -2017-032 a ed February 06, 2017 ---------- J -------------- FILE - ll------------- Issued On: Feb -06-2017 BOARD OF HEALTH ---------------------------------------------------------------------------------- 0 7757 0 Town of North Andover HEALTH DEPARTMENT CHECK #: 946 J- DATE:.A - 9-,.20/7 LOCATION: -)5Y d!2UJerc)r4 alL H/O NAME: .26-y a Ah r CONTRACTOR NAME: 74ecia-r Type of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type. $ 0 Funeral Directors 0 Massage Establishment 0 Massage Practice 0 Offal (Septic) Haukt*�* 0 Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco $ 0 Trash/Solid Waste Hauler $ 0 Well Construction $ SEPTIC Systems: 0 Septic - Soil Testing $ 0 Septic - Design Approval $ 0 Septic Disposal Works Construction (DWC) $ 0 Septic Disposal Works installers (DWT) $ 0 Title 5 Inspector $ [I Title 5 Report $ Other.- (Indicate) $ He�it-Agent Initials White - Applicant Yellow - Health Pink - Treasurer f RECEIVED ` FFA G 6 'Z017 Application for Septic Disposal System ow Construction Permit - TOWN OF LTovNDE AMOT $350.00 - Full Repair NORTH ANDOVER, MA 01845 $175.00 - Component Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal system* [g-R'pair or replace an existing system component — What? t2i t?i e �Alic A. Facility II ,form Address or Lot # �Vlo ewcf_'e�Wr City/Town /s,4 `oc318-0000. d 2.- *TYPE OF SEPT]jr.- SYSTEM*: ➢ ❑ Pump ravity (choose one) ***If pump system, att ch copy of electrical permit to application*** ➢ &�_5nventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No !/ If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) 2. What is the Make? What is the Model? 11/DjC>�� i City/Town St Zip Code i 5i 7 i—/�'' --- i Email address Telephone Number 3. Installer Information f Name Name of Company Addr s City/town to ip Code 0 49 & (` Telephone Numberell Phone # dpossi /e lease) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 • sfi Application for Septic Disposal System Construction Permit — TOWN OF NORTH ANDOVER, MA 01845 TODAY'S DATE $350.00 - Full Repair $175.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Weesidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to a ure the construction and maintenance of the afore -described on-site se ag d" al s tem in accordance with the provisions of Title 5 of the Envir n nt de as ell as the Local Subsurface Disposal Regulations for the Town of Nort do u stand that until a final Certificate of Compliance has been issued by thi Bard f al he installed system is not approved. 65211111 e Date /% pli`ati n Approve y`(Bt�'ard Health Representative) Name Da e Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No / 2. Project Manager Ohligation Form Attached.? Yes No 3. Pump System? If so, Attach copy ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, allpaperworkreceived? Yes No Missing: 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover ensed installer for the cons ction for the septic system for the property at: a zi K.,;; �' (Address of septic system) For plans by Relative to the application of 164iy t�{ti G (Installer's name) Dated f` o ay s ate And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits.and Board of Health approved plans rior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I. understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (V5 inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdeptgtownofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions bathe homeowner, general contractor, or any other persons shall absolve me of this obligation. / Undersigned Licensed Septic Installer: (T ate)/fj (Nat -5e — Print) — igne ) rry North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 754 Boxford Street MAP: 105.A LOT: 0018 INSTALLER: Stewart's DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATEF 0 BED BOTTOM INSPECTION. DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properlyabandoned' ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: DISTRIBUTION -BOX M/z Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution [� >Speed levelers provided (not required) Schedule 40 PVC Pipe Comme ts: � YUGkP,T6 Le, L. FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer M Drinking vV�ter end T=E: A Guici� for Privt:�te SII o`vners A word about this publication) This brochure provides private well owners with t basic information about the gasoline additive chemical methyl tertiary -butyl ether t (MTBE). You can get more information about drinking water and MTBE from the resources listed at the end, and you can get help from your local health department, oto by Bruce F Do you have a private well? About 42 million people in the U.S. get their drinking water from household wells, springs, cisterns, and streams (instead of getting piped water supplied by public water systems). Although the federal government does not supervise private wells, most states have requirements for home well installation. Gasoline is one of many pollution threats to the ground water that supplies your well, If you are a private well owner, the best way to make sure your drinking water is safe is to test it! More importantly, if your water supply is clean now, you can take steps to protect it from pollution in the future (see the section, How can you, protect your drinking water, frotn pollution risks?,below). What is MTBE? MTBE (methyl tertiary -butyl ether) is a chemical added to gasoline to increase octane. Its use began in the 1970's to replace lead in gasoline. After 1995, many metropolitan areas of the country with smog problems also added MTBE to gasoline because it helps to reduce harmful emissions from automobile exhaust. Adding MTBE to gas has been one way to meet EPA's oxygenate mandate. Why is MTBE a drinking water concern? Gasoline and heating oil travel through pipelines and are also distributed by truck to above ground and underground storage tanks. Underground storage tank leaks and spills provide major sources of MTBE. In addition, people store gasoline in cars, boats, planes, lawn mowers, chain saws, generators, and off- road vehicles. Therefore, farm and residential releases, car accidents, spills, boats, and storm water runoff also release gasoline into the environment. MTBE moves quickly through soil, dissolves easily in water, and takes longer to break down than some other chemicals. Could MTBE be in your water? The US Geological Survey has found MTBE in ground water in 24 states, though gasoline with MTBE poses a risk wherever it is used, transported or stored. The USGS has found MTBE in water roughly five times more often and at higher concentrations in areas of the country where MTBE has been used as a fuel additive to reduce pollution. Your local health department may know if people are finding MTBE in your area. For most people, water with MT13E in very low concentrations tastes and smells "nasty," bitter, or like turpentine. However, natural or water treatment chemicals can hide or increase taste and odors in drinking water. Typically, the levels of any contaminant increase very slowly in a well as the contaminated water moves from the source into the well. The result is that people drinking the water every day may not notice a change in the taste or odor. Over time they may become accustomed to the taste and smell. You may discover the problem only when someone who has not been drinking contaminated water (perhaps a friend from across town or an out-of- town visitor) notices that the water tastes or smells funny, If you suspect contamination, you may want to pay to get your water tested for MTBE. It costs about $150 per sample, and your state can give you a list of laboratories certified to test for MTBE. EPA recommends yearly testing of private water supplies for nitrate and colifornh bacteria. Some states recommend other testing and your local health department may do these water quality tests for you. How much MTBE is too much? Most people can taste and smell MTBE in very small amounts. According to EPA's Drinking Water Advisory, EPA reviewed health effects studies in 1997 and noted that drinking water with MTBE levels of 20 to 40 "parts per billion" (acceptable taste and odor) would probably not pose health risks. MTBE at 20 ppb in water is about the same as one drop in 500 gallons of water. EPA has efforts underway to fill some of the data gaps on health effects of MTBE and the extent of its occurrence in drinking water supplies. Current data on MTBE levels in ground and surface waters indicate widespread and numerous detections at low levels of MTBE. However, in studies to date, only about one percent of the ground and surface water testing positive for MTBE has levels higher than 20 ppb. Leaks and spills from storage tanks have caused a limited number of drinking water wells to have high concentrations of MTBE, Keep in mind that gasoline contains many chemicals, some of which could be in higher concentration in your water and a much more serious health concern. Immediately contact your local health officials if your water tastes or smells suspicious, and remember to test! Do you need to take further action concerning MTBE? If you answer "no" or "unknown" to any of the questions in the following checklist, you should get more information (see the resources at the end of this brochure). If a question does not apply to you, just skip it. A Checklist for identifying MTBE problems Yes No Unknown Have you tested your well water in the last 12 months? If gasoline is sold or stored within 1 mile of your well, have you tested your water specifically for MTBE at least once? Have you asked the health department if there is any known groundwater contamination reported in your community? If you have an underground fuel storage tank (UST), have you tested the tank for leaks in the last 12 months? If you have an above -ground fuel storage tank (AST), have you tested the soil around the tank to determine if there have been leaks, drips, or spills? If you have an AST, is it protected with concrete containment and do you closely monitor the tank for leaks, drips, and spills? If you have either an AST or UST, do you have procedures to prevent leaks, drips, or spills and as well as methods to clean them up immediately? If there has been a vehicle accident or other instances of fuel spills on or near your property, have you tested for MTBE since those occurrences? Have you tested your water upon recognizing a change in taste, smell, or appearance? If you use gasoline -powered equipment, do you prevent leaks, drips, and spills and do you clean them up immediately? Resources Available in Your Sate Public Health You should first call your local or state public health department concerning local drinking water MTBE issues. Your local office may have some information about MTBE contamination, if it has occurred in your vicinity. A listing of and links to all state health agencies may be found at http://www.fda.gov/oca/sthealth.htm. Natural Resources and Environmental Quality Each state has a department of environmental or natural resource protection that works closely with the federal Environmental Protection Agency. These state offices help individuals keep their drinking water safe by providing infonnation about well construction and protection Listings of and links to all state departments may be found at http://risk.LvAornl.gov/CRE/CRE_eco_state.html. Q000eratve :--ntension County Cooperative Extension agents can help you evaluate risks to your drinking water supply, and find local sources of assistance. Listings of and links to all state University and Cooperative Extension offices may be found at http://www.rceusda.gov/1700/statepartners/usa.htm. These state web sites in turn will lead you to your county contacts. Links to state Farm'A'Systftine'A'Syst programs may be found by clicking "Resources' at http://www. uwex.edu/farmasyst, or call 608-262-0024. What can you do if you have MTBE contamination? Make sure that you get a "certified treatment system" and consult with resources listed at the end of this brochure before you purchase a product. One not-for-profit, non- government organization, NSF International, certifies products to meet national and international standards. (See Other Internet Websites at the end of this brochure) How can you protect your drinking water from pollution risks? MTBE in gasoline is just one of many types of chemicals that can contaminate your drinking water if not properly used and stored. In addition to gasoline, pesticides, herbicides and other chemicals are used on farms and around households. Use chemicals only as directed by the manufacturer, never apply more than is recommended, and follow proper clean up procedures. Don't build stockpiles! Stockpiling excess chemicals near your home or on your farm could be a contamination problem waiting to happen. Protect your ground water supply when you build, modify, or close a well. Inspect septic systems, maintain your well cap and surface seals, keep well maintenance records, and do not drink from flooded wells. Take preventative steps to avoid contamination from fuel stored in an underground or above -ground storage tank. Use the checklist provided in this brochure to determine if you need to take action based upon your current or past use and storage of gasoline. Use the Home ¢A* Syst and Farm `A* Syst Pollution Assessment Programs to assess the risk of gasoline and chemical use and storage on your farm or near your home. On the internet access http://www.uwex.edu/farmasyst (click on "search" then select "Petroleum Product Management" or `Private Drinking Water Supply" under the Household Topic Search to find worksheets developed in your state or region), To find program contacts in your state, click on the "Resources" button on this web site, or call 608-262-0024. How real is the threat of MTBE contamination? The Environmental Protection Agency and many scientific organizations continue to study the health risks and total environmental threat from gasoline containing MTBE. Fourteen states — nine of which are not required to use a fuel additive to limit air pollution in certain areas, have partially or completely banned the use of MTBE within their borders or made other regulations on its use. Even if MTBE is banned, it will be many years before it is eliminated from the environment. According to a report in the March 2001 Successful Farming magazine, even a minor spill of gasoline containing MTBE is a big threat to ground water supplies. In one instance, just ten gallons of gasoline containing MTBE was spilled as a result of an automobile accident on one person's property. This single event led to MTBE contamination of the water supply for twelve families. Summary You can protect your water supply through good practices that prevent contamination and by testing your water regularly. There is a great deal of information and there are many services available on the World Wide Web if you have a computer and an internet service provider, You can get much of the same information by calling the telephone numbers listed for the resources below. The US EPA and many states have free printed materials about MTBE and other water related topics, photo by Ken Hammond diagram by Betsy True (Resources Available Nationwide The Farm"A"Syst and Honte"A°Syst Programs, 608.262. 0024, http://www.uwex.edu/farmasyst, provide farm and home environmental assessment materials and other publications that can help you protect your water supply. Supplies of this brochure may be obtained from this office. United States Environmental Protection Agency A number of publications and general information are available via the web site of the EPA Office of Water, Ground Water and Drinking Water: http://www. epa.gov/safewater/mtbe.httW, and through EPA's general MTBE information web page: http://www. epa.gov/mthe/. These web pages provide an overview of the MTBE issue and recent related actions by EPA. You can go from the "safewater" web page through links to get your local drinking water information (`memo to the states'), drinking water standards, and many other water -related subjects, Both pages also contain many links to EPA and other sites concerning MTBE. You can call the Safe Drinking Water OW) Hotline at 800-426-4791 Monday through Friday 9:00am to 5:30pin EST to find out where to get your water tested, and for information specifically on MTBE and other drinking water issues. You can also obtain hard copy EPA publications at no cost by calling the National Service Center for Environmental Publications (NSCEP) 800.490-9198, or the Water Resource Center (WRC) 202.566.1729. WRC may be reached by fax at 202-566.1736; or email: center.water- resourceCepa.gov. Anyone with access to the EPA web site is welcome to print, copy and distribute publication listings. EPA publications have no copy -right restrictions. The Educational Resources Information Center (ERIC) 800- 276-0462, and the National Technical Information Service 800.553.6847 MIS), provide EPA publications for a fee. Information on states that have used MTBE reformulated gasoline is included in Control of M7BE in Gasoline (EPA 420-F-00-010), available at www.epa.gov/otaq/ consumer/fuels/mtbe/f00010.htm. Drinking Water Advisory; Consumer Acceptability and Health Effects Analysis (EPA -822-F-97- 009) can be downloaded from http://www.epa.gov/OST/drinking/mtbe.htmi, or obtained from the SDW Hotline. The EPA Underground Storage Tank (UST) web site, http://www.epa.gov/swerustl/, is another good source of relevant inforntation. This site includes a link to the EPA/UST State Investigation Reports on MTBE, which can be accessed directly at http://www.epa.gov/swemsti/ mtbe/mtbestat.htm. Other Internet Web Sites and US Geological Survey Contacts with Valuable Information Concerning MTBE: NSF International, http://www.nsf.org, operates a product certification program for water treatment equipment that is rated for MTBE reduction in drinking water. You can find out about water filtration and obtain names of equipment manufacturers at this web site. NSF's general telephone number is 800-673-6275• Water Quality Association (WQA), http://www.wga.org, is another organization that discusses water quality issues such as MTBE and has periodic updates on research in MTBE remediation. WQA's telephone number is 630-505.0160. American Water Works Association (AWWA) has an MTBE Resource Center, http://www.awwa.org/mtbe/fact.htfn. AWWA offices in Denver can be reached at 303-794-7711 or in Washington DC at 202.628-8303. US Department of Health and Human Services, Public Health Services, Agency for Toxic Substances and Disease Registry provides ToxFAQs on MTBE at http://www. atsdr.cdc.gov/tfacts91.htm1. Answers to frequently asked health questions are available by calling 800-447.1544. GAO Testimony: MTBE Contamination from Underground Storage Tanks, by John B. Stephenson, director, natural resources and environment, before the Subcommittee on Environment and Hazardous Waste, House Committee on Energy and Commerce. GAO -02-753T, May 21, 2002. http://www.gao.gov/ This brochure was funded by a grant from the US EPA Office of Ground Water and Drinking Water, Agreement eC%826881-01-0, and produced jointly by the National Farm*A*Syst/Home*A*Syst j Qf'fce, and UW -Extension Center for Environment and Energy. These web sites contains information on MTBE and other chemical contamination of ground and surface water, http://wwwsd.cr.usgs.gov/nawga/vocns/ or http://water.wr.usgs.gov/mtbe/. Or you can call 1-888- ASK-USGS for information pertaining to biology, geology, hydrology, or mapping, Also, you will find state contacts for the Earth Science Information Centers at http://mac.usgs. gov/mac/isb/pubs/forms/esicstat.htmi, Materials Available From Selected State Programs California: MTBE in Drinking Water Fact Sheet, http:// www.dhs.cahwnet.gov/ps/ddwem/chemicals/ MTBE/mtbeindex.htm Iowa: UST Web Site — contains MTBE -specific information, http://www.state.ia.us/dnr/organiza/ wmad/lgbureau/ust/ Maine: MTBE Fact Sheet, http://www.state.me.us/dep/ rwm/publications/wprotec.htm. Missouri: MTBE Fact Sheet, http://www.dnr.state. mo.us/mtbe New Hampshire: Fact Sheets on MTBE and related issues, http://www.des.state.nh.us/factsheets/ws/ ws-3.19.htm Oregon: MTBE Fact Sheet, http://www.deq.state.or.us/ wmc/cleanup/mtbefctsht.htm Issuent fra4her an a of Gcx�per atil elExtensiffilTylorkMA a rrr8 and um 0, 91 at c p r tion wtt th US. partmean f ricrrltnre mt ersity of Wiscotuiu- .itenslot Goopet stir Ext sr Unirerslt} o Wiscon, in-Esteits ton pror ides a vat o pot tunittes in - yntent and programming iatc u In it e I curd A requirement Ifyou need it is formation in an lteruatioe format. coartact the 0%fic of Fqual Opportunity and versify Ptrogr•ams or caU .pension Pub fishing at 08 2- 55. photo by Gene Alexander Page 1 of 1 DelleChiaie, Pamela From: Sawyer, Susan Sent: Monday, November 26, 2007 10:04 AM To: DelleChiaie, Pamela Subject: pis mail the MTBE letter to ... According to the GIS Addresses within 1/8 of a mile of 742 Boxford St. �{ � V 754 Boxford St - David Hart 729 Boxford St - Jeffery Simmons 725 Boxford St - John Glasko j ` 730 Boxford St - Brian Volke j I 770 Boxford St - Peter Breen 115 Ogunquit Rd. — Peter Breen This is the current recommended radius Susan Sawyer, REHS/RS Public Health Director 978 688-9540 11/26/2007 COMMONWEALTH OF MASSACHUSETTS W EXECUTIVE OFFICE OF ENERGY & ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 5 NORTHEAST REGIONAL OFFICE 205B Lowell Street, Wilmington, MA 01887 ® (978) 694-3200 DEVAL L. PATRICK IAN A. BOWLES Governor Secretary TIMOTHY P. MURRAY LAURIE BURT Lieutenant Governor Commissioner February 27, 2008 Peter and Kerry Breen RE: North Andover 770 Boxford Street 770 Boxford Street North Andover, MA 01845 RTN: 3-27511 . NOTICE OF RESPONSIBILITY NOTICE OF NEED TO CONDUCT IMMEDIATE RESPONSE ACTION PER M.G.L. c.21E & 310 CMR 410.00009 the MCP THIS IS AN IMPORTANT NOTICE. FAILURE TO TAKE ADEQUATE ACTION IN RESPONSE TO THIS NOTICE COULD RESULT IN SERIOUS LEGAL CONSEQUENCES. Dear Mr. and Mrs. Breen: The Massachusetts Department of Environmental Protection (MassDEP) has. received information that indicate a release of hazardous materials occurred at 770 Boxford Street (the subject property). Testing of groundwater from downgradient sampling wells and. drinking water wells detected the presence of benzene and methyl -tertiary butyl ether (MTBE) (see attachments). These findings indicate a likely release from a gasoline underground storage tank formerly used on the subject property. Based on this information, MassDEP hereby issues you a Notice of Responsibility. Please note that exposure to residents associated with drinking water contamination at. 730 and 742 Boxford Street has been addressed. Thc`home owners have installed carbon filtration units on their drinking water well supply lines. NOTICE OF RESPONSIBILITY As described above, MassDEP believes that 770 Boxford Street or portion(s) thereof is a disposal site as defined in the Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c. 21E, and the Massachusetts Contingency Plan', 310 CMR 40.0000 (the This information is available in alternate format. Call Donald M. Gomes, ADA Coordinator at 617-556-1057. TDD Service 1-9787694-3492. http://www.mass.gov/dep • Fax (978) 694-3499 01 Printed on Recycled Paper North Andover, 770 Boxford Street, RTN 3-27511 Page 2 Notice of Responsibility MCP). The assessment and cleanup of disposal sites is governed by M.G.L. c. 21E and the MCP. This release requires one or more response actions. The purpose of this notice is to inform you of your legal responsibilities under state law for assessing and/or remediating the subject release. For purposes of this notice, the terms and phrases used herein shall have the meaning ascribed to them by the MCP unless the text clearly indicates otherwise. STATUTORY LIABILITIES MassDEP has reason to believe that you are a Potentially Responsible Party (a PRP) with liability under M.G.L. c. 21 E, § 5, for response action costs. Section 5 makes the following parties liable to the Commonwealth of Massachusetts: current owners or operators of a site from or at which there is or has been a release/threat of release of oil or hazardous material; any person who owned or operated a site at the time hazardous material was stored or disposed of; any person who arranged for the transport, disposal, storage or treatment of hazardous material to or at a site; any person who transported hazardous material to a transport, disposal, storage or treatment site from which there is or has been a release/threat of release of such material; and any person who otherwise caused or is legally responsible for a release/threat of release of oil or hazardous material at a site. This liability is "strict", meaning it is not based on fault, but solely on your status as an owner, operator, generator, transporter or disposer. It is also joint and several, meaning that you may be liable for all response action costs incurred at the site, regardless of the existence of any other liable parties. The MCP requires responsible parties to take necessary response actions at properties where there is or has been a release or threat of release of oil and/or hazardous material. If you do not take the necessary response actions, or fail to perform them in an appropriate and timely manner, MassDEP is authorized by M.G.L. c. 21E to have the work performed by its contractors. By taking such actions, you can avoid liability for response action costs incurred by MassDEP and its contractors in performing these actions, and sanctions which may be imposed for failure to perform response actions under the MCP. You may be liable for up to three (3) times all response action costs incurred by MassDEP. Response action costs include, without limitation, the cost of direct hours spent by MassDEP employees arranging for response actions or overseeing work performed by persons other than MassDEP or their contractors, expenses incurred by MassDEP in support of those direct hours, and payments to MassDEP's contractors. (For more detail on cost liability, see 310 CMR 40.1200.) MassDEP may also assess interest on costs incurred at the rate of twelve percent (12%), compounded annually. To secure payment of this debt, the Commonwealth may place liens on all of your property in the Commonwealth. To recover the debt, the Commonwealth may foreclose on these liens or the Attorney General may bring legal action against you. You may also be liable to the Commonwealth for damages to natural resources caused by the release. Civil and criminal liability may also be imposed under M.G.L. c. 21 E, § 11, and civil administrative penalties may be imposed under M.G.L. c. 21A, § 16 for each violation of M.G.L. c. 21E, the MCP, or any order, permit or approval issued thereunder. North Andover, 770 Boxford Street, RTN 3-27511 Page 3 Notice of Responsibility NECESSARY RESPONSE ACTIONS You must employ or engage a Licensed Site Professional (LSP) to manage, supervise or actually perform the necessary response actions at the subject site. You may obtain a list of the names and addresses of the licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals (Telephone: 617-556-1091). If one has not been submitted, a Release Notification Form (RNF) must be submitted to MassDEP pursuant to section 310 CMR 40.0333 within 60 calendar days of the initial date of oral notification to MassDEP of a release pursuant to 310 CMR 40.0300 or from the date the MassDEP issues a Notice of Responsibility (NOR), whichever occurs earlier. Initial site investigation activities in accordance with 310 CMR 40.0405 are necessary. Unless a Response Action Outcome Statement (RAO) or Downgradient Property Status Submittal (DPS) is submitted earlier, a completed Tier Classification Submittal pursuant to 310 CMR 40.05 10, and, if appropriate, a completed Tier I Permit Application pursuant to 310 CMR 40.0700, must be submitted to MassDEP within one year of the initial date notice of a release is provided to MassDEP pursuant to 310 CMR 40.0300 or from the date MassDEP issues a Notice of Responsibility (NOR), whichever occurs earlier. The MCP requires persons undertaking response actions at disposal sites to perform Immediate Response Actions (IRAs) in response to "sudden releases", Imminent Hazards and Substantial Release Migration. Such persons must continue to evaluate the need for IRAs and notify MassDEP immediately if such a need exists. If Imminent Hazard conditions are identified at the site, you must notify MassDEP within two hours and seek approval to perform an Immediate Response Action (IRA) to abate the Imminent Hazard. Furthermore, an Imminent Hazard Evaluation Form must be submitted to MassDEP if Imminent Hazard condition(s) exist. The MCP requires persons undertaking response actions at a disposal site or portion thereof to submit to MassDEP a Response Action Outcome Statement (RAO) prepared by an LSP in accordance with 310 CMR 40.1000 upon determining that a level of No Significant Risk already exists or has been achieved (Class A & B Permanent Solution RAOs) or that no Substantial Hazards exist (Class C Temporary Solution RAOs). The subject site shall not be deemed to have had all the necessary and required response actions taken unless and until a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c. 21E and the MCP. Pursuant to MassDEP's "Timely Action Schedule and Fee Provisions", 310 CMR 4.00, a fee of $750 must be included with an RAO statement that is submitted more than 120 calendar days after the initial date of oral notification to MassDEP of a release pursuant to 310 CMR 40.0300 or after the date MassDEP issues an NOR, whichever occurs earlier, and before Tier Classification. A fee is not required for an RAO submitted to MassDEP within 120 days of the date of oral notification to MassDEP, or the date MassDEP issues an NOR, whichever date occurs earlier, or after Tier Classification. It is important to note that you must dispose of any Remediation Waste generated at the subject location in accordance with 310 CMR 40.0030 including, without limitation, contaminated soil and/or debris. Any Bill of Lading accompanying such waste must bear the seal and signature of an LSP or, if the response action is performed under the direct supervision of MassDEP, the signature of an authorized representative of MassDEP. North Andover, 770 Boxford Street, RTN 3-27511 Notice of Responsibility Page 4 MassDEP encourages parties with liabilities under M.G.L. c. 21E to take prompt action in response to releases and threats of release of oil and/or hazardous material. By taking prompt action, you may significantly lower your assessment and cleanup costs and avoid the imposition of, or reduce the amount of, certain permit and annual compliance fees for response actions payable under 310 CMR 4.00. If you have any.questions relative to this notice, you should contact Andrew Friedmann at the letterhead address or (978) 694-3217. All future communications regarding this release must reference the Release Tracking Number (RTN 3-27511) contained in the subject block of this letter. Sincerely, Andrew Friedmann, Ph.D. John F. Miano, Jr. Environmental Analyst, Site Management Branch Chief, Site Management BWSC, NERO BWSC, NERO cc: DEP Data Entry/File (NOR/ISSUED), (C&E/INTLET) cce: Susan Sawyer, Public Health Director, North Andover, ssawyer@townofnorthandover.com David R. Hart in North Andover, MA - SearchBug Listing Details Page 1 of 2 S�arc`-lJ Search the Web: Search Your fro 6 QSganXFinder Home People Finder Company Finder Professional search tools to find and investigate people Details on D i Hart Search » Deta i David R Hart 754 Boxford St North Andover, MA 01845 (978) 686-6.144 SearchBug Exclusive Info • county: available • phone service by: available • residence type: available • years listed at this address: available. �L I i i A Larger Map Public Records Research Tools Print 9 Send to Phone isl Remove 2 Investigate David R Hart Back. ground Check Up to 20 years of past and current address and phone number. Possible aliases / maiden names, relatives, roommates, neighbors, bankruptcies, property ownership, tax liens, judgments, marriages, divorces, dea registrants, and website ownership Nationwide Criminal Records Court, case, conviction date, offenses, warrants, charges, sentence, sex offenders, Patriot Act database P.roperty_Records_, Ownership, value, date last sold, and the assessor's parcel number • Ownershn by_the ep rson • Owngrship of the_residence _Bankruptcies _& Liens Up to 20 years of past information for bankruptcy filings, federal and state tax liens, and civil judgments / Business Qwnership Check if the person is the owner or corporate officer of a business. Get business name, address and phone number. E-mail Address Check person's email address and Reunion.com profile (35 million people registered) Cell Phone Number Find person's cell phone number, phone company, primary number on account along with the billing address Illy -VY Vulll W How to hide ads? Name Age Address Phone City, State Possible Relatives t NART,_DAVID R 37 Available Available Boxford, MA Available Cambridge, MA North Andover, MA North Reading, MA Free People Search By Name By Phone By Address Find name and home phone number of a US resident from home address (reverse address search). 754 boxford http://www.searehbug.com/peoplefinder/details.aspx?TYPE=byaddress&ADDRESS=754... 12/13/2007 North Andover Board of Assessors Public Access naR7y �4ntNUSE� Return to the Home page click on logo New Search Sales Summary Residence Detached Structure Condo Commercial Comparable Sales Tome ofNO Axlldover Roam Of ASSessam Page 1 of 1 Property Record Card Parcel ID: 210/105.A-0018-0000.0 Community: North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e qqq. �. 754 BOXFORD STREET Location: 754 BOXFORD STREET Owner Name: HART, DAVID R Owner Address: 754 BOXFORD STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 5 - 5 Land Area: 1.02 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 2392 soft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 518,200 470,600 Building Value: 310,300 288,400 Land Value: 207,900 182,200 (Market Land Value: 207,900 Chapter Land Value: LATEST SALE Sale Price: 425,000 Sale Date: 10/21/2001 Arms Length Sale Code: Y -YES -VALID Grantor: DAVID WYANT Cert Doc: DOC 76358 Book: 00108 Page: 0241 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=990513 12/13/2007 0 CL 0 D 'v ni J 0 na 0 v v o� 0 v a, n 0 �o ni o' 0 3 3 0 q 0 'D m fi fD O -h TI EO O -'A, Z� 4 C rt O o, n O O n rt D O� c� avv P,0 o c � 3 0 cD rt vas � � o c D m v 0 c 3 rt D l CL 3 O l l � m fi fD O -h TI EO O -'A, WILLIAM? F. WELD Govemo: ARGEO PAUL CELLUCCI Lt. Governor COMMONWEALTH OF MASSACHUSETTS �aP EXECUTIVE OFFIC OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL.PROTECTION ONE WINTER STREET. BOSTON. MA103I08 61 i1 -29? -5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �y Q + I CERTIFICATION Property Address: ' t SLjLJCkc � S�' 1v v�fAddress of Owner: Date of Inspection: Of different) Name of Inspector: l 3 aRJfe—qaA I am a DE pro= d s sy tem in ector Dursuant to $edion 15.340 of Title 5 (310 CMR_ 15.000) Company Name: Mailing Address: I [ -In6— 0. ; P(q` d fro Telephone Number: TRUDY CO)E Secretary DAVID B. STRUHS Commissioner CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below 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 d' systems. The system: Passes Conditionally Passes _ Need Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: u� ��.,.� Date: �- � 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 or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate 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: Check A, 8, C, or D: A] SYSTEM PASSES: Iaveno foundany 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. COMMENTS: 81 SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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. (revised 04/25/97) Papa 1 of 10 DEP on the World Wide Web: http:/Avww.magnet state.Ma.usldep 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: yj�Xv S} Owner: ��( 's S. Date of Inspection: Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled 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): broken pipe(s) are replaced 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 the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER a WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. I well The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a 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. Method used to determine distance (approximation, not valid). 3) OTHER (revised 04/45/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: 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. Yes No Backup of sewage into facility or system component due to an 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. 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 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 piogram requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/75/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or 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 if they ate not available with N/A. (f The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria. related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (soviaed 04/25/97) Maga 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �� — N ` ►—'" C/ Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 1f C> (t.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: 1 Garbage grinder (yes or no): Laundry connected to sysIT (yes or no): � Seasonal use (yes or no): N Water meter readings, if vailable (last two (2) year usage (gpd): Sump Pump (yes or no):J Last date of occupancy: Rk' QY\ Wet WI. COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:gallons/day Grease 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 date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)S If yes, volume pumped: i ckOV gallons T Reason for pumping: V YSS,p&� AIN— TYPE OF EM 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed Jif known) and source of information: 1 & �L r O �- Sewage odors detected when arriving at the site: lyes or no) n10 (revix*d 04/25/97) Pago 9 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: tJ�Lf P - Owner: M a Date r: Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: f Material of constru on: iron L-400PC other (explain l/ �,� 1 n �us,e t A &.. r,.,n t A Distance from p+ivate water supply well or suction lire Diameter 4 t Comment : c nd"¢ion of joints, venting, evidence of leakage, etc.) SEPTIC TANK: - (locate (locate on site plan) u Depth below grade: Material of construction: —concrete _metal Fiberglass _Polyethylene _,other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: h �x Sludge depth: tk Disfance from top of �'ludge to bottom of outlet tee or baffle: Scum thickness _ t r Distance from top of scum to top of outlet tee or baffle: a 11 Distance from bottom of scum to bo m Ppf� outlet tee or baffle - How dimensions were determined: v`( o Comments: (recommendation for pumping, cond'' �Of 4. intezrity. Gvidertce of leakage, etc,"J" GREASE TRAP: (locate on site plan). of linuid level in, relagon tq outlet 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 tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structure integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 20 ok SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: VI �;q is.A 0, A,jLZaA(— Owner: M ovj 1 sa Date of Inspection: VV ll TIGHT OR HOLDING TANK: 'u (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _otherlexplain) Dimensions: Capacity: gallons Design flow: gallons/dav Alarm level Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: v (locate on site plan) Depth of liquid level above outlet invert: Comments: if level and distribution is equal, evidence f solids carryov evi encs of le a e int or out of x et .) UCUM'v�tC t V m GLS PUMP CHAMBER: (-O-ul�l (locate on site plan) <j 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.) (revised 04/2S/971i Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Is `t� Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ "hot on site plan, if possible; excavation ot required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: r leaching fields, number, dimensions: l4�k-P_A c% 90 K �S overflow cesspool, number: Alternative system: Name of Technology: Comments: (note cond'tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) tion -- �� S� Q _t" d c} -ca) Suzz CESSPOOLS: V\CIW_ (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: F inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: Vlf:iv _ (locate on site plan) Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (zavised 04/25/97) Page a of 10 Dimensions: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Y Property Address: Owner: ►� /�C��S� Date of Inspection.- SKETCH nspection:SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) D-Pv�, to,¢kk Ig ? � , +-, 3�! L45' rt� f3 As- p- = C .t .13 l( I _ 3 V 35 3 (revised 04/25/97) Page 9 of 10 (��USE'- O'flVQ 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C T SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater _a Feet Please indicate..all the methods used to determine High Groundwater Elevation: -__Obtain frfrom Design Plans on record �eterminiej��nm `erservatoSite (Abutting property, observation hole, basement sump etc.) local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local --excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) a_s Ate:y'a�z QV -C F (revised 04/25/97) Page 10 of 10 TEI_: (50fl) 475-147^ fid I�I FA"- (508) 475-54' 7$aF �:{i.j��•�" . BA ��l: SON L-NTE[�zl'I��ISCSj INC. tb 4 / Fxcivalhir - Witer & S,,%ver Lines - Septic Systems & humping Service I i I Arglih Road a Andover; Mass. 0 113 10 Title 5 Tnspec_ti.on Report F'-ope.r, ty Address : ----------------- ownr- �`��C I.) CIO Date of Inspect i -on : -- ----- ---- ----- Ply report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I. hereby disclaim any further operation of your current septic system: Ne11 J, Bateson Bateson Enterprises Inc. Page 11 of 11 Board e3f Health Nort ... An0-0ver,Hans. } APPR CM DATY.. J� l V i FAIL OK SEPTIC SISTEM INSTALLATICK CHECK LIST LOT 1� S SA2PR07i ID EXCAVATIM OK FAIL 1. Distance Tot a. Wetlands b. Drains C. Well 2. Water Line Location 3• No PVC Pipe 4. Septic Tank-- - a. Tees --Length & To Clean Out Covers _. b. Cement Pipe to Tank - On Both Sides of Tank a 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flog 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits ~ a. Dimnsions b. Stone Depth c. Splash Pads d. Tees e. Cment Pipe to Pit -.Both Sides f. Clean Dou61e Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e; Water Table Nor. -h# Andover Subsurface disposal, system check list r-" Page 2 fail Rr;*g.10.2 Reg.10.4 Reg.11 .2 Reg.11 .4 Reg.11 .10 zeg.11.11 Reg.15.1 Reg. 15.1 Reg. 15.4 Reg. 15.8 Reg. 3.7 Reg• 14 1 Reg..14.3 Reg.14-4 14.-_5 Re g.14.6` Reg.14.7 Reg.1 4.1 Reg. 9.1 Reg. 9.6 Distribution Boxes ka) Slope greater than 0.08 (b Sump Leaching Pits Leaching pits are pr rred where the installation is possible (a) Calcu� ations of leaching area (minimum 500 S.F.) (b Spacl.ng c Surface drainage 2% d. -' Cover SSmaterial t lT� fec cY'1l P, Sk A". Leaching Fields h:Greater than 20 minutes/inch Area (minimum --900 S.F.) Construction of field Surface. drainage 2% i (e 20' from cellar wall or inground swimming pool Leaching Trenches (a Calculationsleaching area (min. 500 S.F.). (b Spacing (4 . min. 6 ft. with reserve between) -,(c Dimensi s - (d Con ructiori- (e� one M, Surface drainage 2% Downhill Slope �Slo /x = to be shown4'a 150 = �to be shown Pumps (a) Appro al (b) Sta -by power �iJBS`,,gI`ACE DISPOSAL SYSTEM CHE); K LI NT ,a.. t, ' ?NORTH A11DOVER BOARD OF HEALTH I . Pref giy 7- ' p D4TE PROVIDED i .5 Reg. 6 Fail DISAPPROVED DATE TIME REASON .5 ✓(4--1 The submitted plan must show as a minumum: (a) the lot to be served (area,dimensions,lot //,abutters) (Planning Board files) (b). location and log of deep observation holes -distance to ties (c) location and results of percolation tests -distance to ties (d) design calculations & calculations showing required leaching area (e) location and dimensions sf system (including reserve area) f existing and proposed contours g� location of any wet areas within 100' of the sewage disposal system o t- disclaimer (check wetlands mapping) (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) ( j) _ known sourzes_= of=ii,rater supply -Within -2001 --of sewage -- ;� disposal -_sys-tem or disclaimer_. (k) location of any proposed well to serve the lot (100' from leaching facility) (1) location of water lines on property (10' from.leaching facilities) ,�m) location of benchmark - driveways garbage disposers no PVC is to be used in construction q) a profile of the system (elevations of basement, plumb( pipe septic tank, distribution box inlets and outle:-s, distribution field piping and any other elevations) maximum ground water elevation in area of sewage dispo, ystem ls) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a) Capacities - 150% of flow, water table, tees, depth of tees, access, pumping, (.b`) Cleanout c 10' from cellar wall or inground swimming pool d) 25' from subsurface drains r I COMMONWEALTH OF MASSACHUSETTS EXECUT"(OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A - CERTIFICATION Property Address: /e/ N r Owner's Name: Zil&j CA -,&17 Owner's Address: Date of Inspection: Name of Inspector: Company Name: i Mailing Address: _ Telephone Number: C,er'Ld TCvV►f CF= I3OAR:i) � (1 [oAl 1 A 2001 l 'a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate 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 5 (310 CMR 15.000). The system: asses Conditionally Passes Needs Further valuation by the Local Approving Authority F ils Inspector's Signature: I Date: " D 1 The system inspector shallAbmit a copy of this inspection 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 regional 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. Title 5 Inspection Form 6/15/2000 page I -4 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: fVa f G t� ' RZ/ Owner: -JT' _ Date of Insp on: -• d / Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: �havenot 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: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with if approval of Board'ofHealifi) r. ,n - .� >; _ f.... .. _ . _- :- - -- - -_ I broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ND explain: broken pipe(s) are replaced obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ►-o (✓f Owner: Date of Inspec n: y no! C-6 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the d system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform i bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and ' the-preger�ce of atmiiianfnitrog&r� d nitrate`nilrogen 7s e 4 alto or -less than -5 ppm, proVided-that no other",- " failure criteria are triggered. A copy of the analysis must be attached to this form. i 3. Other: Page 4 of l 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: M4 47 I%I-U� Date of Ins tion: ^a D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool �,iac _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or r ..,,clogged SAS or cesspool _ ' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _jesquid depth in cesspool is less than 6" below invert or available volume is less than'/, day flow 6+' Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number — of times pumped 10 �y portion of the SAS, cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. P*"' Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _moi Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ 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 if the well water analysis, performed at a. 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 than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) 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. -.+� To be considered a large sysfem tti`e system must serve a ficility with a design flow of 10,000 gpd to 15;000 gpd• . You must indicate either "yes or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply . the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area – IWPA) or a snapped Zone Il of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: jtfa Date of Ins tion: �! Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system componeh s pumped out i ,,the previ~o .s ry o weeks Has the system received normal flows in the previous two week period ? V Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) 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 and location of the Soil Absorption System (SAS) on the site has been deteinined based on: f— ^:.:. -" ;.Xw°,.,:"'"'�.' i - -"y`7-j ry.ga` 'fit -e. - - "` - , Yeo Existing information. For example, a plan at the Board of Health. Determined 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)] 5 tPage 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address• 23— Owner: G4/ Date of Ins ion: Al — 7rrO' FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Y Number of bedrooms (actual): Y_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms)�/Pp Number of current residents: Does residence have a garbage grinder (yes or no): IV6 Is laundry on a separate sewage system (yes or no):/[if yes separate inspection required] Laundry system inspected (ye or no): _ Seasonal use: (yes or no):A 4 t} r Water meter` readings, if available (last 2 years usage (gpd)): Sump pump (yes or no):%J 0 Last date of occupancy: QCCU01ie C� COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease 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 date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records {' Source of information: hp rnQ ( t#) AA -e -L {' Was system pumped as part of the inspection (yes or no):dS ' { If yes, volume pumped/ QC"lgallons -- How was quant ty��pumped determined? j! y ` Reason for pumping: %AJ S 47-0 GT' 0 ie— TYPE,0F SYSTEM eptic tank, distribution box, soil absotpticm system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odo—rs detected when arriving at the site (yes or no):m lrVeX. Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: U� owner: /A) ao"'— Date of Insp ion: BUILDING SEWER (locate on site plan) Depth below grade: J� Materials of construction: ast iron _40 PVC _other (explain): Distance from private water supply well or suction line: p L,%, i^ 11 QA Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: lz (locate on site plan) Ir Depth below grade: -6 Material of construction: oncrete _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) � C, Dimensions: Sludge depth: Distance from top of slur�ge to bottom of outlet tee or baffle: Scum thickness: � Distance from top o scum to top of outlet tee or baffle: Distance from bottom of scum to bottom—of outlet tee or afile: �! How were dimensions determined: 11-1 _ EZff!k5 A! ✓ Comments (on pumping recommendations, Inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet invert, evidence of leakage. etc.): e;. GREASE TRAP: _(locate 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 tee 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.): N •`rw A Page g of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 'doxicold kol Aza 4. Owner: Date of Ins a tion: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) 1 Depth below grade: Material of construc ion: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flows gallons/day 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.): DISTRIBUTION BOX:(/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: .A,�(Ly/"0.11 IV 1 S A - Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into 0 out of bo ,etc.): JUS I I S CQ � r'Z d tk(� _ d 1i * L 0 19 -rr I b u T` I &P PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): %k Alarms in working order (yes or no): Comments (note condition pf pump chbmber, condition,o f pumps and appurtenances, etc.), r - " Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: d Owner: 14 _ Date of Insp ion: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type 4 v s A leaching pit's, number: r $ l leaching chambers, number: leaching galleries, number: leaching trenches, number, length: aching fields, number, dimensions: t t LC4 MX overflow cesspool, number: _ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS: (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): �.� , ,'�-_ .r Comments (note condition of soil, sig►s of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Continents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 z Page 10 of l 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:6- &K(Aai a d 1 LJ�Bv" Owner: G✓ q k�7 Date of Insp ion: v" 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. ys r V 10 �b a t, Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I�N,FORMATION (continued) Property Address: tUb f rr ISG{ /VD A7N am. -01& Owner: Date of Insp ion• L --79-- 0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water,. feet Please indicate (check) all methods used to determine the high ground water elevation: V Obtained from system design plans on record - If checked, date of design 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 Rust describe how you established the high ground water elevation: IAC h,,I[__T VLAIJ ..r 4r •. w i e � i ' DelleChiaie, Pamela From: Sawyer, Susan Sent: Monday, November 26, 2007 10:04 AM To: DelleChiaie, Pamela Subject: pls mail the MTBE letter to... According to the GIS Addresses within 118 of a mile of 742 Boxford St. 754 Boxford St - David Hart 729 Boxford St - Jeffery Simmons �1 725 Boxford St - John Glasko v I 730 Boxford St - Brian Volke i 770 Boxford St - Peter Breen I 115 Ogunquit Rd. — Peter Breen This is the current recommended radius Susan Sawyer, REHS/RS Public Health Director 978 688-9540 11/26/2007 0 Page 1 of 1 5 r' PUBLIC HEALTH DEPARTMENT Community Development Division November 26, 2007 Dear Homeowner, This correspondence is an advisory from the North Andover Health Department. Please take note if you currently have a private well on your property that provides your home with drinking water. On October 05, 2007, residents at 742 Boxford Street reported odors in their drinking water and elected to have their well water tested by a private laboratory. On October 20, 2007, this office received a laboratory report from the testing, which identified methyl(t)butylether (MTBE) and benzene in the drinking water at concentrations of 240 micrograms per liter (gg/1) and 0.80 lag/l, respectively. MTBE and benzene are common chemicals associated with gasoline. The Massachusetts Department of Environmental Protection (MassDEP) has established a drinking water standard of 70 µg/1 for MTBE and 5.0 Wl for benzene. MTBE reported from the October 5, 2007 sampling event was above MassDEP's standard of 70 ug/l. In response to the discovery of this drinking water contamination, the Health Department contacted MassDEP and accepted an offer to have MassDEP collect and test additional drinking water samples. On November 9, 2007, MassDEP collected another drinking water sample from 742 Boxford Street. An initial screening of this sample found 320 ug/1 MTBE and 6.5 ug/l benzene, thereby confirming the earlier sampling results. 'This sample was forwarded to the Wall Experiment Station 'State Laboratory for analysis. When the 'State Laboratory results are available, they will be communicated to the homeowner as soon as possible. MassDEP will continue to investigate this matter and work towards identifying the source of the contamination. Per MassDEP's recommendation, the Health Department is now sending this information to you, due to your proximity to 742 Boxford Street. Please note that both MassDEP and the Health Department are recommending that you have your well water tested for MTBE, benzene, and other volatile organic compounds associated with gasoline by either a private laboratory or by MassDEP. If you elect to have your well water tested by MassDEP, MassDEP will request that you provide them with either verbal or written permission allowing them onto your property to conduct the water testing. They will also request that you provide to them, to the extent possible, any information you have regarding the depth of your well and any home treatment and/or 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com of PUBLIC HEALTH DEPARTMENT Community Development Division November 26, 2007 Dear Homeowner, This correspondence is an advisory from the North Andover Health Department. Please take note if you currently have a private well on your property that provides your home with drinking water. On October 05, 2007, residents at 742 Boxford Street reported odors in their drinking water and elected to have their well water tested by a private laboratory. On October 20, 2007, this office received a laboratory report from the testing, which identified methyl(t)butylether (MTBE) and benzene in the drinking water at concentrations of 240 micrograms per liter (gg/1) and 0.80 lag/l, respectively. MTBE and benzene are common chemicals associated with gasoline. The Massachusetts Department of Environmental Protection (MassDEP) has established a drinking water standard of 70 µg/1 for MTBE and 5.0 Wl for benzene. MTBE reported from the October 5, 2007 sampling event was above MassDEP's standard of 70 ug/l. In response to the discovery of this drinking water contamination, the Health Department contacted MassDEP and accepted an offer to have MassDEP collect and test additional drinking water samples. On November 9, 2007, MassDEP collected another drinking water sample from 742 Boxford Street. An initial screening of this sample found 320 ug/1 MTBE and 6.5 ug/l benzene, thereby confirming the earlier sampling results. 'This sample was forwarded to the Wall Experiment Station 'State Laboratory for analysis. When the 'State Laboratory results are available, they will be communicated to the homeowner as soon as possible. MassDEP will continue to investigate this matter and work towards identifying the source of the contamination. Per MassDEP's recommendation, the Health Department is now sending this information to you, due to your proximity to 742 Boxford Street. Please note that both MassDEP and the Health Department are recommending that you have your well water tested for MTBE, benzene, and other volatile organic compounds associated with gasoline by either a private laboratory or by MassDEP. If you elect to have your well water tested by MassDEP, MassDEP will request that you provide them with either verbal or written permission allowing them onto your property to conduct the water testing. They will also request that you provide to them, to the extent possible, any information you have regarding the depth of your well and any home treatment and/or 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com purification system that may be in use. The water test being offered by MassDEP is at no cost to •' the home owner. If you chose to have MassDEP conduct your water testing, please contact Larry Immerman, Environmental Analyst at MassDEP, at (978) 694-3347 at your earliest convenience to set a time. Finally, a fact sheet on MTBE has been included with this notice. you, Susan Sawyer, REHS/RS Public Health Director Cc: Mark Rees, Town Manager Board of Health Members Boxford Health Department MassDEP Encl. Fact Sheet 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com EPA Ground Water & Drinking Water > breadcrumb? > Consumer Factsheet on: BENZE... Page 1 of 4 sr� U.S. Environmosital Protection Agency Academy this chemical at home or work. o rW Ground Water& Drinking Water a ¢ r Recent Additionj I Contact Us I Print Version Search: 0 +rye cis° 41 PR4jC EPA Home > Wa er > Ground Water & Drinking Water > Consumer Factsheet on: BENZENE Drinking Water and Consumer Factsheet on: BENZENE Health Basics i Frequently Asked Questions List of Contaminants Local Drinking Water Information As part of the Drinking Water and Health pages, this fact sheet is part of a larger b � publication: Drinking Water National Primary Drinking Water Regulations Standards List of Contaminants & This is a factsheet about a chemical that maybe found in some public or private MCLS drinking water supplies. It may cause health problems if found in amounts greater Regulations & than the health standard set by the United States Environmental Protection Agency Guidance (EPA). Public Drinking Water Systems What is Benzene and how is it used? Source Water Protection Benzene is a clear, colorless aromatic liquid. It is highly flammable. The greatest use of benzene is as a building block for making plastics, rubber, resins and Underground Injection synthetic fabrics like nylon and polyester. Other uses include: as a solvent in Control printing, paints, dry cleaning, etc. Data & Databases Drinking Water The list of trade names given below may help you find out whether you are using Academy this chemical at home or work. Safe Drinking Water Act Trade Names and Synonyms: National Drinking Water Advisory Benzol 90 Council Pyrobenzol Water Infrastructure Polystream Coal naphtha Security Phene b � Why is Benzene being Regulated? ` In 1974, Congress passed the Safe Drinking Water Act. This law requires EPA to determine safe levels of chemicals in drinking water which do or may cause health problems. These non -enforceable levels, based solely on possible health risks and exposure, are called Maximum Contaminant Level Goals. The MCLG for benzene has been set at zero because EPA believes this level of protection would not cause any of the health effects described below. Based on this MCLG, EPA has set an enforceable standard called a Maximum Contaminant Level (MCL). MCLs are set as close to the MCLGs as possible, considering the ability of public water systems to detect and remove contaminants using suitable treatment technologies. The MCL has been set at 5 parts per billion (ppb) because EPA believes, given present technology and resources, this is the lowest level to which water systems http://www.epa.gov/safewater/contaminants/dw contamfs/benzene.html 11/26/2007 EPA Ground Water & Drinking Water > breadcrumb? > Consumer Factsheet on: BENZE... Page 2 of 4 can reasonably be required to remove this contaminant should it occur in drinking water. These drinking water standards and the regulations for ensuring these standards are met, are called National Primary Drinking Water Regulations. All community water supplies must abide by these regulations. What are the Health Effects? Short-term: EPA has found benzene to potentially cause the following health effects when people are exposed to it at levels above the MCL for relatively short periods of time: temporary nervous system disorders, immune system depression, anemia. Long-term: Benzene has the potential to cause the following effects from a lifetime exposure at levels above the MCL: chromosome aberrations, cancer. How much Benzene is produced and released to the environment? Production of benzene has increased: from about 9.9 billion lbs. in 1984 to over 12 billion lbs. in 1993. Benzene is released to air primarily from fumes and exhaust connected with its use in gasoline. Other sources are fumes from its production and use in manufacturing other chemicals. In addition, there are discharges into water from industrial effluents and losses during spills. From 1987 to 1992, according to the Toxics Release Inventory, releases of benzene to water and land totalled over 2 million lbs. These releases were primarily from petroleum refining industries, with the greatest releases occurring in Texas. What happens to Benzene when it is released to the environment? If benzene is released to soil, it will either evaporate very quickly or leach to groundwater. It can be broken down by some soil microbes. It may also be degraded in some ground waters. If benzene is released to surface water, most of it should evaporate within a few hours. Though it does not degrade by reacting with water, it may be degraded by microbes. It is not likely to accumulate in aquatic organisms. How will Benzene be Detected in and Removed from My Drinking Water? The regulation for benzene became effective in 1989. Between 1993 and 1995, EPA required your water supplier to collect water samples every 3 months for one year and analyze them to find out if benzene is present above 0.5 ppb. If it is present above this level, the system must continue to monitor the benzene levels. If contaminant levels are found to be consistently above the MCL, your water supplier must take steps to reduce the amount of benzene so that it is consistently below that level. The following treatment methods have been approved by EPA for removing benzene: Granular activated charcoal in combination with Packed Tower Aeration. How will I know if Benzene is in my drinking water? If the levels of benzene exceed the MCL, 5 ppb, the system must notify the public via newspapers, radio, TV and other means. Additional actions, such as providing alternative drinking water supplies, may be required to prevent serious risks to http://www.epa.gov/safewater/contaminants/dw contamfs/benzene.html 11/26/2007 y EPA Ground Water & Drinking Water > breadcrumb? > Consumer Factsheet on: BENZE... Page 3 of 4 public health. Drinking Water Standards: Mclg: zero Mcl: 5 ppb Benzene Releases to Water and Land, 1987 to 1993 (in pounds): Water TOTAL 564,546 Top Six States" TX 1,436 AL 199,642 LA 137,599 CO 0 NM 0 IL 3 Major Industries" Petroleum refining Primary Metal Ind. Industrial chemicals Alkalies, chlorine Land 1,539,385 1,135,994 0 4,347 40,793 38,199 34,110 32,411 1,049,800 133,339 18,078 73,000 250,103 122,240 0 * Water/Land totals only include facilities with releases greater than a certain amount - usually 1000 to 10,000 lbs. Learn more about your drinking water! EPA strongly encourages people to learn more about their drinking water, and to support local efforts to protect and upgrade the supply of safe drinking water. Your water bill or telephone books government listings are a good starting point. Your local water supplier can give you a list of the chemicals they test for in your water, as well as how your water is treated. Your state Department of Health/Environment is also a valuable source of information. For help in locating these agencies or for information on drinking water in general, call: EPAs Safe Drinking Water Hotline: (800) 426-4791. For additional information on the uses and releases of chemicals in your state, contact the: Community Right -to -Know Hotline: (800) 424-9346. List of Contaminants Safewater Home I About Our Office I Publications I Links I Office of Water I En Espafiol I Questions and Answers EPA Home I Privacy and Security Notice_ I Contact Us Last updated on Tuesday, November 28th, 2006 URL: http://www.epa.gov/safewater/contaminants/dw_contamfs/benzene.html http://www.epa.gov/safewater/contaminants/dw contamfs/benzene.html 11/26/2007 EPA Ground Water & Drinking Water > breadcrumb? > Consumer Factsheet on: BENZE... Page 1 of 4 � zED gx- U.S. avimnoont l" Protodion Agency Q Y Ground !dater & Drinking !dater .' w fl `� Recent Additions I Contact Us I Print Version Search: EPA Home > Water > Ground Water & Drinking Water > Consumer Factsheet on: BENZENE Drinking Water and Consumer Factsheet on: BENZENE Health Basics Frequently Asked Questions List of Contaminants Local Drinking Water Information As part of the Drinking Water and Health pages, this fact sheet is part of a larger publication: Drinking Water National Primary Drinking Water Regulations Standards List of Contaminants & This is a factsheet about a chemical that may be found in some public or private MCLS drinking water supplies. It may cause health problems if found in amounts greater Regulations & than the health standard set by the United States Environmental Protection Agency Guidance (EPA). Public Drinking Water Systems What is Benzene and how is it used? Source Water Protection Benzene is a clear, colorless aromatic liquid. It is highly flammable. The greatest use of benzene is as a building block for making plastics, rubber, resins and Underground Injection synthetic fabrics like nylon and polyester. Other uses include: as a solvent in Control printing, paints, dry cleaning, etc. Data & Databases Drinking Water The list of trade names given below may help you find out whether you are using Academy this chemical at home or work. Safe Drinking Water Act Trade Names and Synonyms: National Drinking Water Advisory Benzol 90 Council Pyrobenzol Water Infrastructure Polystream Coal naphtha Security Phene D e [�w Why is Benzene being Regulated? In 1974, Congress passed the Safe Drinking Water Act. This law requires EPA to determine safe levels of chemicals in drinking water which do or may cause health problems. These non -enforceable levels, based solely on possible health risks and exposure, are called Maximum Contaminant Level Goals. The MCLG for benzene has been set at zero because EPA believes this level of protection would not cause any of the health effects described below. Based on this MCLG, EPA has set an enforceable standard called a Maximum Contaminant Level (MCL). MCLs are set as close to the MCLGs as possible, considering the ability of public water systems to detect and remove contaminants using suitable treatment technologies. The MCL has been set at 5 parts per billion (ppb) because EPA believes, given present technology and resources, this is the lowest level to which water systems http://www.epa.gov/safewater/contaminants/dw contamfs/benzene.html 11/26/2007 EPA Ground Water & Drinking Water > breadcrumb? > Consumer Factsheet on: BENZE... Page 2 of 4 can reasonably be required to remove this contaminant should it occur in drinking water. These drinking water standards and the regulations for ensuring these standards are met, are called National Primary Drinking Water Regulations. All community water supplies must abide by these regulations. What are the Health Effects? Short-term: EPA has found benzene to potentially cause the following health effects when people are exposed to it at levels above the MCL for relatively short periods of time: temporary nervous system disorders, immune system depression, anemia. Long-term: Benzene has the potential to cause the following effects from a lifetime exposure at levels above the MCL: chromosome aberrations, cancer. How much Benzene is produced and released to the environment? Production of benzene has increased: from about 9.9 billion lbs. in 1984 to over 12 billion lbs. in 1993. Benzene is released to air primarily from fumes and exhaust connected with its use in gasoline. Other sources are fumes from its production and use in manufacturing other chemicals. In addition, there are discharges into water from industrial effluents and losses during spills. From 1987 to 1992, according to the Toxics Release Inventory, releases of benzene to water and land totalled over 2 million lbs. These releases were primarily from petroleum refining industries, with the greatest releases occurring in Texas. What happens to Benzene when it is released to the environment? If benzene is released to soil, it will either evaporate very quickly or leach to groundwater. It can be broken down by some soil microbes. It may also be degraded in some ground waters. If benzene is released to surface water, most of it should evaporate within a few hours. Though it does not degrade by reacting with water, it may be degraded by microbes. It is not likely to accumulate in aquatic organisms. How will Benzene be Detected in and Removed from My Drinking Water? The regulation for benzene became effective in 1989. Between 1993 and 1995, EPA required your water supplier to collect water samples every 3 months for one year and analyze them to find out if benzene is present above 0.5 ppb. If it is present above this level, the system must continue to monitor the benzene levels. If contaminant levels are found to be consistently above the MCL, your water supplier must take steps to reduce the amount of benzene so that it is consistently below that level. The following treatment methods have been approved by EPA for removing benzene: Granular activated charcoal in combination with Packed Tower Aeration. How will I know if Benzene is in my drinking water? If the levels of benzene exceed the MCL, 5 ppb, the system must notify the public via newspapers, radio, TV and other means. Additional actions, such as providing alternative drinking water supplies, may be required to prevent serious risks to http://www.epa.gov/safewater/contaminants/dw contamfs/benzene.html 11/26/2007 EPA Ground Water & Drinking Water > breadcrumb? > Consumer Factsheet on: BENZE... Page 3 of 4 public health. Drinking Water Standards: Mclg: zero Mcl: 5 ppb Benzene Releases to Water and Land, 1987 to 1993 (in pounds): Water TOTAL 564,546 Top Six States* TX 1,436 AL 199,642 LA 137,599 CO 0 NM 0 IL 3 Major Industries* Petroleum refining Primary Metal Ind. Industrial chemicals Alkalies, chlorine Land 1,539,385 1,135,994 0 4,347 40,793 38,199 34,110 32,411 1,049,800 133,339 18,078 73,000 250,103 122,240 0 * Water/Land totals only include facilities with releases greater than a certain amount - usually 1000 to 10,000 lbs. Learn more about your drinking water! EPA strongly encourages people to learn more about their drinking water, and to support local efforts to protect and upgrade the supply of safe drinking water. Your water bill or telephone books government listings are a good starting point. Your local water supplier can give you a list of the chemicals they test for in your water, as well as how your water is treated. Your state Department of Health/Environment is also a valuable source of information. For help in locating these agencies or for information on drinking water in general, call: EPAs Safe Drinking Water Hotline: (800) 426-4791. For additional information on the uses and releases of chemicals in your state, contact the: Community Right -to -Know Hotline: (800) 424-9346. List of Contaminants Safewater Home I About Our Office I Publications I Links I Office of Water I En Espariol I Questions and Answers EPA Home. I Privacy_and_Security Notice I Contact Us Last updated on Tuesday, November 28th, 2006 URL: http://www.epa.gov/safewater/contaminants/dw_contamfs/benzene.htm] http://www.epa.gov/safewater/contaminants/dw contamfs/benzene.html 11/26/2007