HomeMy WebLinkAboutTitle V Inspection Report - 544 FOSTER STREET 7/25/2017 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
544 Poster Street
Property Address
Karen Herman
Owner Owner's Name
information
for every tion is
requireNorth Andover MA 01845 7-25-2017
----
page. Cityfrown 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.
Important:When A. Genera[ Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Neil J. Bateson
use the return Name of Inspector
key.
Bateson Enterprises Inc.
� Company Name
111 Argilla Road
Company Address
Andover MA 01810
City/Town State Zip Code
978-475-4786 SI-15
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 ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
C
7-25-2017
Insp c is ignatur Date
The system inspector shall submit 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 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 61Dtficial tnspection 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
t
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
page. Cityrrown State Zip Code date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E 1 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 exfiitration 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):
t5lns,doe•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
StaEe Zip Code Date of inspection
page city/Town
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pimps/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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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
f5ins.do�-rev.6116 Tit€a 5 official€ospwion Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Herman
Owner Owners Name
information is
required for every North Andover MA 01845 7-25-2017
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Hoard 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:
Pressure line four pump leaking at shut off valve in pump chamber. Needs to be replaced or repaired
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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 1/2 day flow
j t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
j
Tine 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is
required for every North Andover MA 01845 7-25-2017
page. CitytTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Z 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 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.]
❑ ® 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
f
El Elthe system is within 400 feet of a surface drinking water supply
0
❑ ❑ 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.dog.rev.6116 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
State Zip Code Date of Inspection
page. Citylrown
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
® El 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.
® ElDetermined 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 3
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
151ns.doc•rev.6116 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
State dip Code Date of Inspection
page. Citylrown
D. System Information
Description:
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Yes
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: Current
Date
Commerciallindustrial Flow Conditions.
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
544 Foster Street
Properly Address
Karen Herman
Owner Owner's Name
information is
required for every North Andover MA 01845 7-25-2017
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancyluse: date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped November 2016, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank.
Reason for pumping: Inspect tank&tee & baffle.
p
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 IIA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doq•rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
t Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
State Zip Code date of Inspection
page. CitylTown
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
15 years old, 5-22-2002, as built plan. Pump&blower was replaced lastear, owner.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
3
Depth below grade: 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.):
4" PVC through wall, 4" PVC to tank. 2" & 3" PVC in house, no leaks visible.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 4'
3"
Sludge depth:
t5ins.dop•rev.6116 Title 5 official Inspecllon Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm- Not far Voluntary Assessments
' 544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
z2°
1"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8°
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet baffle ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped
septic tank. Inlet tee has riser to grade. Outlet baffle has riser to grade.
Grease Trap(locate on site plan):
Depth below grade: feet
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:
i
15ins.doc•rev.6116 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
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
page. City/Town. State Zip Code Date of Inspection
D. System Information (coat.)
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
Design Flow: 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
t5ins.dop•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
v Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
" 544 Foster Street
Property Address
Karen Herman
Owner Owners Name
information is North Andover MA 01845 7-25-2017
required for every
State Zip Code date of Inspection
page Gityf'rown
D. System Information (coat.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Pump Chamber(locate on site plan):
Pumps in working order: E Yes ❑ No*
Alarms in working order: ® Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump tank ok. Pump ok. Floats ok. Pump discharge pipe leaking at shut off valve . Needs to be
replaced or repaired. Pump was replaced last year.
"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:
u
151ns.dorr•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I
Commonwealth of Massachusetts
u Title 5 official inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
page cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number: —
❑ leaching trenches number, length:
® leaching fields number, dimensions:
36' x 41'
❑ overflow cesspool number:
® innovative/alternative system
Type/name of technology: Fast media to pressure dosing leach area
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface. Dug test hole in middle of system, no
water to stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site pian):
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
l5ins.do¢•rev.6/16 Title 5 Official inspection Form;Subsurface Sewage Disposal system•Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
page. City/Town State Zip Code 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.dot•rev.6116 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5
544 Foster Street
Property Address
Karen Herman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
page. Cityffown 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
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t5ins.doc•rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Djsposaf System•Page 15 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Merman
Owner Owner's Name
information is North Andover MA 01845 7-25-2017
required for every
page. Cityfrown State Zip Code Cate of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 11-15-2000Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
0
t5ins.dop•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 16 o€17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
544 Foster Street
Property Address
Karen Herman
Owner Owners Name
information is
required for every North Andover MA 01845 7-25-2017
page City[Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, S, 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
15ins.dog•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage disposal System•Page 17 of 17
Summary Record Card ganeraled on 7117/2017 2:57:20 PM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-1043-0004-0000,0
Parcel Id 16333
544 FOSTER STREET
HERMAN, KAREN
544 FOSTER ST
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 0.69 Acres
FY 2017
UB Mailing Index
Name/Address Type Loan Number Active/lnact. From Until
HERMAN, KAREN Payor
544 FOSTER ST
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id, 18085.0-544 FOSTER STREET Last Billing pate 4/6/2017
3180113 03 Cycle 03 Active
UB Services Maint.
Account No.3180113
Service Cade Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 11
WTR WATER 01 ALL METER SIZE 72.20 11
UB Meter Maintenance
Account No.3180113
Serial No Status Location Brand Type Size YTD Cons
44152938 a Active 00 ERT HH b Badger w Water 0.63 0.63 255
Date Reading Code Consumption Posted Date Variance
6/13/2017 281 a Actual 15 -27%
3/10/2017 266 a Actual 19 4/12/2017 2%
12/12/2016 247 a Actual 19 1/23/2017 -47%
9/13/2016 228 a Actual 35 10/24/2016 152%
6/17/2016 193 a Actual 15 8/2/2016 3%
3/14/2016 178 aActual 14 4/22/2016 11%
12/14/2015 164 a Actual 13 1/20/2016 -33%
9/11/2015 151 a Actual 19 10/16/2015 46%
6/11/2015 132 a Actual 12 7/24/2015 9%
3/18/2015 120 a Actual 12 4/28/2015 -3%
12/15/2014 108 a Actual 12 1/15/2015 -57%
9/16/2014 96 aActual 30 10/15/2014 159%
6/12/2014 66 aActual 11 7/16/2014 -1%
3/13/2014 55 aActual 11 4/11/2014 -26%
12/13/2013 44 a Actual 15 1/17/2014 -17%
9/13/2013 29 a Actual 18 10/15/2013 13%
6/14/2013 11 aActual 11 7/24/2013 -71%
4/12/2013 0 n New Meter 0 7/24/2013 -100%
3/20/2013 928 m Manual estimate 50 4/22/2013 85%
12/26/2012 878 m Manual estimate 30 1/9/2013 26%
9/24/2012 848 m Manual estimate 25 10/15/2012 15%
6/18/2012 823 m Manual estimate 20 7/16/2012 21%
3/20/2012 803 m Manual estimate 15 4/14/2012 27%
MSG
12/29/2011 788 m Manual estimate 15 1/17/2012 -45%
MSG
9/16/2011 773 a Actual 25 10/13/2011 97%
6/13/2011 748 a Actual 12 7/20/2011 -20%
3/15/2011 736 a Actual 15 4/13/2011 0%
u
Commonwealth of Massachusetts
City/Town of .
Systetn Pumping-Record
Form 4
DEP has.provided this form far use-by local Boards of Health. ether forms maybe used,but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Heap to determine the foram they use.The System Pumping Record must be submitted to
the local.Board of Health or other approving authority.
A. Faci-l�ty lnformi ation
I. System Location: Lei#1 ight f&t of ft 1 Right rear of house, Left/right side of house, Lett I
Right side of building, Le fight front of buildirig, Left/Right rear of building, Under deck
. Address � ! .� �-•,� �! ` .-►� V`..��'�,
CitylTawn ! state - Zip Gods
2. System Owner.
Name.
Address(if different from location)
Citylrawn ' Sta1e-t� � Zip Cade
P
'telephone Number
. 1
.B. Putmping Record �
9. Date of Pumping pate 2. Qu6ntity Pumped: Gallons
.3. Type-of system: ❑ Cesspool(s) is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo if yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
,,,__,�
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Erste rises Ina
Company
7. Locati here contents-were disposed:
.L Lowell Waste Water
�_7-36= �
Sign a WHbul Rate
)rm4.dar,•06103 System Pumping Record•Page 1 of 1
Invoice
Invoice Number:
49117
44 Commercial Street Tele: (508) 880-4233 Invoice Date:
Raynham, MA 02767 Fax: (508) 880-7232 Apr 20,201
Page: 1
Sold To: Ship To:
Karen Herman 544 Foster Street
544 Foster Street North Andover,MA 01845
North Andover,MA 01845
Customer ID Serial Number Payment Terms
2908W 2N281 Net 30 Days
Sales Rep ID Shipping Method Ship Date Due Date
Best Way 5120117
Quantity Item Description Unit Price Extension
L0 Annual Renewal Annual Renewal of Service Contract for Onsite 380.00 380.00
Wastewater Treatment System effective Date
05/01/17 through 04/30118
------- ==_ ._ -GUTMEREANBDRETURNBOTTOMPOOMONWITHPAYMENT-----=---.-- ___________-- ----
Karen
. .Karen Haman 544 Foster,Street 49117
544 Foster Street North Andover,MA 01845
North Andover,MA 01845
2908W
Subtotal 380.00
Sales Tax
Total Invoice Amount 380.00
Check No: Payment Received
TOTAL DUE 3x0.00
44 Commercial Street
Raynham,MA
02767
Tel: (508)880-0233
Fax: (508)880-7232
November 11,2016
North Andover Board of Health
1600 Osgood Street
North Andover, MA 01845
Attention: Health Agent
Reference: FAST'Wastewater Treatment System- Serial Number: 2N281
Attached please find the Field Inspection& Service Report with field test results for
services performed on 10/13/16 at the property of Karen Herman located at 544 Foster
Street,North Andover,MA.
Please call if you have any questions or require additional information.
Sincerely,
Wastewater Treatment Services, Inc.
Service Department
Enclosures
Copy to: Karen Herman
Massachusetts DEP
- ry
i
8450 Cole Parkway,Shawnee,KS 66227,Phone 813-422-0707, Fax 913-422-0808
e-mail:onsit crS-btomicrobics.com, .biom'cro 'cs.com,800-763-FAST(3278)
MASSACHUSETTS FIELD INSPECTION & SERVICE REPORT
For Bio-Microbics FAST'Systems
27505
INSTAL E rLTtON AUTHORIZED=s1t�J1PROVVTbER
Installation Address: 544 Foster Street Name: Wastewater Treatment Services,Inc.
North Andover MA 01845
Owner Name: Karen Ferman
Mail Address: 544 Faster Street Mail Address: 44 Commercial Street
North Andover,MA 01845 Raynbam,MA 02767
Phone: 978-685-1964 Fax: e-mail: Phone: (508)880-0233 Fax: (508)880-7232 e-mail-
.
�' INSTA�;LATION INFORMAT(ON
Mode Sema!No. Startup Date 17ate oflast uump out
MicroFAST.5 2N281 5/29/2002 $1111004
Anoroval Type () General () Provisional () Piloting (x)Remedial () General Denite
easonal esidence O Yes (x) No
Q `- YES N4 MAINTENANCE PERFORMED;AND COMMENTS.
Electrical Panel(s)
Visual Alarm Operating x
Audio Alarm Operating x
(if present)
Blower(s)
Air Inlet Filter Clean x
Blower Hood Vents-Clear x
Excessive Noise x
Excessive Vibration x
'treatment unit(s)
Unusual Odor x
Settleable Solids Test Performed
Pump out Required x
Primary Settling Zone Sludge Depth IT'
Aerobic Treatment Zone Sludge Depth IV
Thickness of Scum Layer 112"
Sludge Level Distance to Outlet
Depth of Ponding Within SAS
Visual Observation Comments:
Measurement Comments:
EFELUEPI7 , . LI .0"lr RESCJl3T
Estimated Daily Flow 444 gpd
pH(Standard Units) 6 to 9 7
Turbidity <40NTU 10.56
Dissolved Oxygen ?2 Mg/L 5.66
Color Clear Clear
Temperature 58
Odor Not Septic Earthy
Effluent Solids (x)None Q Some
Effluent Samples Taken:
Influent: ()pH ()BOD ()CBOD ()TSS ()TKN ()Nitrate ()Nitrite ()'Total Nitrogen()Phosphorus()Spec.Cond, ()Ammonia ()Alkalinity
()Oil/Grease ()VOC ()Fecal Coliform
Effluent: ()pH ()BOD ()CBOD ()TSS ()TION ()Nitrate ()Nitrite ()Total Nitrogen()Phosphorus()Spec,Cond. ()Ammonia ()Alkalinity
()Oil/Grease ()VOC ()Fecal Coliform
Description of any maintenance performed since previous inspection&daring this Inspection: Cleaned Filter,Checked Splash Recycle,Pump(s)
Inspected,Floats)Inspected
Notes and Comments: Pumps and floats have been inspected and are operational
CERTIFIED QpSRATOR N�iME CERT 7
CAT,IQN 1 QMbER SERVICE DATE ,
John Medei€os 17549 10/13/16
OPERATQR SIGNATLI .
i
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