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Home My WebLink About0435 RIVER ROAD - Health 435 River Road,Marstons Mills 060 - 014 -010 a � ;X s TOWN OF BARNSTABLE 1� LOCATION Y35'- 1?11�-14Z A0 SEWAGE # VII.LAGE /V-4a�' ASSESSOR'S MAP & LOTS aZ .o% S NAME&PHONE NO. A/ SEPTIC TANK CAPACITY /� LEACHING FACIL=: (type) /�/X (size) �Xl NO.OF BEDROOMS RM-OR OWNER G�e--eZG PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (ff any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leach n aci ' Feet Furnished by < �„ } �� l /� _ , i �_ � ft+ ae o � c,� �. 53 TOWN OF BARNSTABLE LOCATION XDj/0 A*1_,&eM SEWAGE # Jl` /r7 VILLAGE%JV,Q,/�//S 17leZ .S ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 3 SEPTIC TANK CAPACITY o 6 �r L LEACHING FACILITY:(type) /�/Tr (size) / DU O GPItd' NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 7VW4/ BUILDER OR OWNER 0'-011,V 0,5 kle�2ez C 6 DATE PERMIT ISSUED: Z /d DATE .. COUPLIANCE ISSUED: A ' VARIANCE GRANTED: Yes No 13° �, 0 -01 r�, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereb de for a Permit to Construct or Repair an Individual Sewage Disposal "or Re I Location-Address or Lot No. Installer Address z Other Distribution..b.o-.x....(_;�e Dosing tank ( ) Percolation Test Results Performed by..CME�...1d.AQjJV40.- ............... D a t e..rl�: 7........... Test Pit No. I.......:4"".�'minutes per inch .Depth of Test Depth to ground water.A�.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I1L LF, 5of the State Sanitary Code further o�c� �o operation until a Certificate of Compliance s been e by the rd of health. ' Date ---'--'-' '--- �cro�t ---------------'------'------'---------------------- Da te | Issued � ^ Date � —'''' —'--' — —'— '''—_---'---------------'___---_--''-''''—'_-----'-----_-_--'—'' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ell ....................OF.....�`�.�!'s : ./ta.e.>"" � `....................... Appliratiun for Disposal Works untrurtiun rrrntit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ...... Y . ». ?._......- --� � ,=- ---'-- o. �L ....••.._....................... .......'--"-"..."••'-................. .. -- ... .. Location-Address or Lot No. ......................� »&«= ..GG .'C:: ......................................... ._...........................--...•........ ....--....................................... Owner Address W t Installer Address '. Type of Building ize Lots" _ ........Sq. feet Dwelling—No. of Bedraoms............................................Expansion Attic ( V'arbage Grinder ( � pa, Other—Type of Building 1 ! .............. No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixyres ----•------------------------------•---------------...--.......--•-------•------------..........--•--•-•-- WDesign Flow...... . . ............................gallons per person per�ay. Total daily flow......... .....____........_... Ions. WSeptic Tank—Liquid capacit/� 1_ .gallons Length.?'..:-..... Width.:4i a:Zp... Diameter................ Depth......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No. '. Diameter f�:.. . _..... Depth below inlet...&............ Total leaching area .._r.._sq. ft. z Other Distribution box (X Dosing tank `-' Percolation Test Results Performed by..C#A,6 _.... . V..Z ................................ Date.., ,�Z4- �'�.b�........... ,..a Test Pit No. I......L`6..-----minutes per inch Depth of Test Pit.../6�.......... Depth to ground water.. d.............. rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-------------------------------------------------------------- .---------------- •------------------- --- •---------- •---------- •--------- •----------------- .... 0 Description of Soil........................................................................................................................................................................ U .--------------------------------•------•-•---------••-•--------....'•-•'-•"••--•••--._.........----•-...------------------•----....-----••........----------•---------••---"-----•--•-•---............ W ----------------------------------------------------------------------------------------------------------•--•---------------------....---------------------••----------------••---•-•-•----•------.•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----•--------------------------••---•-----------------..........------=•--------•-••-----.:..------•---•--•----------•---------------.......------------•---------------..............---......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place thy syste in operation until a Certificate of Compliance s been ' s e by the and of health. ,�/ c ...... Date Application Approved By.. = .. .... ......----- ........................................ Date Application Disapproved for the ng reasons----------------•-------...-----•----....------------------------•----------...-----------------------......... ....................................... - Date Permit No.... -/ ------------------------- Issued.. - Date... ...............• THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH 0.1A1..............:..OF... 8 �r' e� a�..! .... ............................. . Trrfif iratr of Tuutplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) ...... b . - v WQ.�f -- ---------------------------------- ---------------------- Y. •- _..." l f ......• 8 = } = I taller at-. �.. $...� �c..� Alt- has been installed in accordance with the provisions of TI F 5 of h tate Sanitary Code as described in the application for Disposal Works Construction Permit No.. .-^ - ------ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... .= f.......................... Inspector.................. • -------•-•----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS OARD�F HE H j� ..............f...L/....... ..OF....p .�l.... ... ...... /�./. ....... �j No...U..l...._.!_. FEE......�✓........ Disposal u/ ------- -- -r s Tunstr ' n rrntit Permission i hereby granted...... -z).1- - ----- - - --._........................----......................-----........... 'J , to Construct ( or Repair ( ) a I.n idu Swage Di sal Ystem at No........&0.. ..._..,�� i�� Street as shown on the application f r Disposal Works Construction it No� '� D ed.._.. . .�....�............ - -1-... ............... Board of ealth DATE __ .. . ... ................... FORM 1255 A. M. SULKIN, INC., BOSTON i , Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every 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. Important:When filling out A. General Information f .forms on the computer, use 1. Inspector: �(J only the tab key to move your Matthew F. Gilfoy cursor-do not Name of Inspector use the return key. B&B Excavation Company Name _I 14 Teaberry Lane Company Address ICI Sandwich. . \ Ma. 02644 City/Town State Zip Code (508)477-0653 S113640 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 10-1-14 Inspect5K Signature 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 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 DER 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•3/13 Title 5 Official InTctiF. bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y. 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. City/Town 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 ® 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: 4 3) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Ilk Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °yt 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 ❑ 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, f 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•3/13 Title 5 Official Inspection 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 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 E ® 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/day flow - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. Cityrrown 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. ❑ ® 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 ❑ ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i _Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. City/Town State Zip Code Date of Inspection 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)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial 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: t5ins•3/13 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 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 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: El 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.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): 2; 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: 1000 gal. Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s . a 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 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 26" Scum thickness 101, Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 7" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Tank should be pumped for maintenance and every 2-3-years thereafter. 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts IN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. City/Town State Zip Code 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 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 l5ins•3/13 Title 5 Official Inspection 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 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to in working order no sign of carryover. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 1 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ 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.): At time of inspection leaching appears to in working order with no sign of hydraulic failure. Water level 210" below invert at time of inspection. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. Cityrrown 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.): i 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•3/13 Title 5 Official 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 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. City/Town 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 A Q O O Ai- Ws' 2 ADZ- Z.r' A3- zq,G- r3 l i2' 7" (33 " 33`3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 16' 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: 4-19-89 Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 435 River Road Property Address Andre Willis Owner Owner's Name information is required for Marstons Mills Ma. 02648 10-1-14 every page. Citylfown State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 F R ID R iQ=q D j F[�B92 '7 CERTIFIED SEPTIC SYSTEM REPORT HEUA ` "T. TOWN OF LE RE � LOCATION FEB ? 3 19e7 HEALT" 435 RIVER RD . TOWNOEE ... MARSTONS MILLS, MA 02648 MAP 060 PARCEL 014 . 010 PREPARED FOR SELLER MR. JON OSWELL 435 RIVER RD . MARSTONS MILLS, MA 02648 BUYER MR. ANDRE WILLIS 435 RIVER RD . MARSTONS MILLS, MA 02648 PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WHUm F.Weld Trudy Coze Gorsenor Saenu+Y An"Paul ce lucci DavidC—m�s lZ l amw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: y35 /�/iG-Z f?/� /� Sim%s i� s Address of Owner. Date of bwpection: (If different) Name of Inspector. Company Name.Address and Telephone Numbr.e 15k'� >X ago �' Z Cyr CERTIFICATION STATEMENT I ontdy that I have personally inspected the sewage disposal system at this address and that the information reported below is true. actzrrate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and ,tea,., enance of=-site sewage disposal systems. The system: (/15asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspeataes 9lpatw.-e: WW4�1� 2/xt Date: The System Inspector&hall submit a copy of this inspec,on report to the Approving Authorty within thirty(30) days of comp).sLing this inspedion. 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. INSPE(.'TION SUMMARY: Cba49z,C,or D: Al,SYSSTTEM PASSES: y I bave not faund any infor=ation which indicates that the system violates any of the failure citeria as defined in 310 CIsd•'tt 15303. Any fujura criteria not evaluated are indicated below. Bl SYSTEM CONDITIONALLY PASSES: Ons or morf system components need to be replaced or repaired. The system. upon completion of the replacement or repair,p maes mspaooa. Iadirsce yea,na or not determined(Y, N, or ND). Describe basis of determination in all instances. Lf-not determined-, explain why cot) _ The septic tank is metal. crackea. struc tuaily unsound. snows subnantal mfltration er ezfiltranon_ or tank failure is unr anent. The system wL'l pass ::.epec.on ::.he existing septic tank is eniacea with a ronformiag septic tank as approved bw the Board of health. 1-71 (revised 11/03/95) 1 One Winm Street a Boston, Massachusetts 02108 • FAX(6171 SWI049 a Telephone(617) 292.5500 • Pnntod an aeeycwd Paper . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addre..r owner. A"i, Date of Insp.otfion: 'Check if the following have been done: v Pumping information was requested of the owner. occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow,rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. U�As built lams have been obtained and exa mined.amtned. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. Z—The system does not receive non-sanitary or industrial waste flow (-'the site was inspected for signs of breakout. All system components, excluding the Sou Absorption System, have been located on the site. i/'The septic tank manholes were uncovered opened. and the interior of the septic tank was inspected for condition of baffles or toes, material of construction, dimensions, depth of liquid. depth of sludge, depth h of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. vThe owner(and occupants. if different from i faaltty pan m owner. were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: y 3c5 r1'ze-. t /fq Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL Design(low gallons Number of bsd:ooms:_ Number of enrrant residents: Garbage Fsndw Vet or no):_J I,aMndry omnsaW to system(,yes or no):& seasonal we(yes or no):" Water meter readings, if available: Last date of oxupancy: P ,��Gr COMMERCIAL/INDUSTRL4jL Type of establishment:_ Design Dow��day Grasse trap present: V'm or no)_ Industrial Wasts Holding Tank p nt: (yes or no)_ Noa�asnits Wage the Title 5 system: (yes or-.no)_ Water meur.readiags,if a ble: Last date of OTHER ) Let date of GENERAL INFORMATION PUMPING RECORDS and source of information: .8yston pumped as part of inspection: or no),LW If yes,vohrme pumped: gallons Beason for pumping: TYPE OF SYSTEM tanI m ge taalr/dis=em:tioa bazlsoil absorption system sin&Cesspool Owrdow Cesspool privy attach pre+ious inspection records, if any ghared�(yes or no) (if yes. other(C plain) AppROZIHAT'E AGE of all components. date installed(if known) and sauce of information: — sewags Odom detected when arriving at the site: eyes or no i �-� (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address U2 Owner. ��•�!? G LJ Date of Inspection: SEPTIC TANK/ (locate on ate plan) Depth below f; da:da Material of Win:4,,c6ncrets_metal_FRP _other(ezplain) / 4 4 /• Dimensions: - SbAp&pth:� �t Distance frvm top of shtcge to bottom of outlet tee or baffle: scum thi�"a 3 )' Distanot tram top of=i:m to top of outlet tee or baffle:� Disraaa from bottom of,scum to bosom of outlet tee or baffle:— Comments: (re ommsndation for pumping, condition of inlet and outlet tees or battles, depth of liquid level in relation to outlet invert, structural integrity, svidsum of leakage, stc.) 7)3'X� Aell'V rZOQ- GRMASE TRAP: (locats on site plan_) Depth bak w gada: Material of oonstru=on: _concrete _FRP _othenexplain, Dimensions: S=th;Ay%sas: Distance from top of scum to to of outlet tee or baffle: Distance from bottom of sc bottom of outlet tee or baffle: Comments: (recommendation for ping,Condition of inlet and outlet tees or bailnes. depth of''quid level in relation to outlet invert, structural integrity, evidence of hahage, a (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Adams �,Z/ O�lci£t L Date of a TIGHT OR HOLDING TANK:_ (beats oa site Plan) Depth below greds: Material of mxuuction: _concrete_metal_FRP other(explam) Dims�icns: capacitr. _gallons Imp flow___g&llons/day Alarm leoeL�_ Comments: (condition of inlet tee,condition of and float switches, etc.) DISTRIBUTION BOX.- (locate as she Plan) Depth of lgwd level above outlet invert:— Commits: v (note if level snd distribution is equal,evidence of solids carryover, evidence of leakage into or out of box. etc.) li l/ 10� /641 t�,L PUMP CHAMBER:_ (Doeate on sits Plan) pumps in wonting orden(yes or not Comments: (note oeaditian of pump chamber,condition PumPs and apPurtensacee. etc-) (revised 11/03/95) T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION•(oontinued) Property Aaare.ac Date of Iaspsoibn. �/��7 BOIL ABSORPTION SYSTEM (SAS):1l (locate on site plain, if poaabk:acivation not regtured. but may be approximated by non-intrusive methods) If not determiaad to be present,explain: Type* Inching pits, number.—t chambers,number_. Iaaehiag plleries, number. Leehiag trmehea, number,length: lrchiag fields,number, dimensions: overflow arspool, number: Comments:(note condition of soil. signs of hydraulic failure. level of ponding, condition of vegetation etc.) CESSPOOLS:_ (bats on site plan) Number and ocafigurstion: Depth-top of liquid to inlet invert: Depth of solids layer Depth of==layer Dimensions of cesspool.- Matsriale of c°matroetion: _ Indication of groundwater: inflow(casspooi must pumped as part of inspection) Comments:(note eoadi b n of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PBIVY:_ (loots an sae plan) Materials cf constrvctio= Dimensions: Depth of solids: Cammmtr(note condition of ages of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 9 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: Owner. ,,. Date of Inspection: j��g7 SBETCR OF SEWAGE DISPOSAL SYSTEM: ioeh-da tim to at vast two permanent references landmarks or benchmarks locate all wells within 100, l i / / / ce- r. W �e W 1 1 i DEFM M GROUNDWATER nsthad d dearminatim car appraxIDatlon: 5 f7'4'L<'/L/l i l//= L�/�T.YiZ I/� 3C�L. %z' �L-3. ��y�" 1�,�<<.c✓ i�7'iF_ /ate if:.>�� ,�. A,'d G.9TG: j f// Gi,� G S G�%� e�Tim,� //:� %/��` 4i�:"r z 7"?74 e" / (revised 11/03/95) /�:�✓.qdG y // g 50,5 _ 50, 0 Of ya'- — ' � 4 r= 2 _ - 9 � k 1 A-,- _. PAP6 A S:T CONCRE ". o 10 - i - 10 20 SEPTIC TAA(K r 1 - P- 64GI - 2 G 52 .0 .ram - 10 36 6 a. py 0 . 2 _ _ �-- Z E,4 Cy/iVC ' T N A SAME ,DZ,5l qN CRI E"RIA IV 5G,G55 F �� LOT J I-IC �,�-., � � r- 18 8 -v r 2.5 GPo/sr= 471 - 03SZR r 14171 D/ f�jT�/ +/ 5/ 21 /87 78 sfx 1 4Pj,� = 78 CAPE ISLANDS G, DUNNING h O f ,k j . ASSUMED DATA !�``>'` KE ETk4 9742 BARN, J/Y.�Li 1f h._ ♦ r.H r, : � 1 yi' +r LOT 1 ' TOW N O L E i gat, tt � � I � � � ; /�. -? _ __. / b � �f/JOd! A:l t�iVJc/iT4�.cF C!/�TC,�/�L f�,�' rrci FEfj ••r: .t • � � ` �, _ - Y /!t.c /�!�'rio,f/s A/Q Tc � Ac rFi.C.� lv'.,, �j' C ;' ) CLf/lt/ S�•t� �L' fD/`f�l9�fE W17i�l 3, o SITE PLAit/ 4 r �- • _ t J 0 H N 0'S 4.1 Al 45 -� r - � '`� c _ VPPzRC14 Pr G;1VZTRINC = ._ _ H,< `t2 R F r 5// AT.• fJo /3oc 6!7 1 \ , Z. S qA1 o� •rA. oz5-3 ' a►Cq wN BY f' - tom