HomeMy WebLinkAbout0698 SHOOTFLYING HILL RD - Health 698 Shootflying Hill Road, Centerville
cll(l 'ACYCLFo�
2° O. .
llll � Z
UPC 12543 '
No,3L R �fi°osrcoNs�J`�
HASTINGS, MN
Commonwealth of Massachusetts 93 �
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�a
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville ✓ MA 02632 7/27/20
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.
A. Inspector Information
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ® Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
7/27/20
Inspector's tgnature 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
2) 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):
****System is comprised of a block cesspool to an overflow block cesspool and they are in the
driveway. Since there are no engineering calculations the components are of unknown strength and
design. System is considered a"Conditional Pass" per Barnstable policy. Per the policy the potential
buyers are to be made aware of the potential safety concerns. I have attached a copy of the policy
and a letter of clarifacation from the Health department
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 'h 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 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owners Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Per town record home was built 1966. There was no info on the system at The BOH
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system Inspection El 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: Weekends
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,.9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: No recent pumping
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
6g Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
1966 per age of the home
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
>10'
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
�C-\- Commonwealth of Massachusetts
�. re Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: /a
fe
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:
Sludge depth:
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�. (P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shooiflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner s Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 6x6 block
❑ innovative/alternative system
Type/name of technology:
l5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal Systen):Formk-,�N,ot for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owners Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The overflow cesspool is in the paved portion of the driveway, it has a 30" cover to grade, it is dry at
this time, bottom of cesspool is 8' below grade, stain line about half way up sidewall, no indication of
past hydraulic failure, structure appears to be structurally sound
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
,Number and configuration
Cesspool to overflow
Depth—top of liquid to inlet invert 5
Depth of solids layer 12"
Depth of scum layer 1/2
Dimensions of cesspool
6x6
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool is located in the gravel portion of the driveway, cover is 8" below grade, outlet T in place, no
indication of past hydraulic failure, structure appears to be structurally sound
t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•� 698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
� l
l
i
l
d S ts<<C
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
rP Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner's Name
information is
required for every Centerville MA 02632 7/27/20
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >15'
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: n/a
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
No info at BOH
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping puts the site at 56'msl and nearby surface water at 34'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
698 Shootflying Hill Rd.
Property Address
Lewis
Owner Owner s Name
information is
required for every Centerville MA 02632 7/27/20
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
o� Town of Barnstable Barnstable
8pR1 Board of HealthQ' 'j
OFF 200 Main Street,Hyannis MA 02601
2007
Office: 508-862-4644
FAX: 508-790-6304
October 9,2012
Revised November 20,2013
Public and Environmental Health Program
Policies,Procedures,and Guidelines
H-10 Components Discovered Beneath Parking Areas and Driveways During Septic System
Inspections Conducted Under 310 CMR 15.301,State Environmental Code,Title 5
No.2012-005
When a DEP certified inspector discovers an H-10 septic system component located beneath a
parking area or driveway during a septic system inspection,conducted under 310 CMR 15.301
State Environmental Code Title 5,the system shall be deemed as a"conditional pass." The
system owner will then be ordered,by the Board of Health,to correct this problem within two(2)
years and will be provided several options to rectify the issue, including by:
a.) replacing the septic system component with a new component relocated into another area
of land which is not beneath any parking area or driveway,and properly abandoning the
discovered H-10 component;or by
b.) replacing the septic system component with an H-20 component beneath the parking area
or driveway,and properly abandoning the discovered H-10 component,(or in the case of
leaching pit,replacing the top of the leaching pit with an H-20 slab top);or by
c.) relocating the parking area or driveway in such a way that no vehicle will have access or
the ability to drive over the existing H-10 septic system component.
If it is unknown whether or not a particular system component which is located beneath a parking
area or driveway, is H-10 or H-20(for example: a leaching pit is located beneath a paved
driveway without an accessible steel cover to grade and there are no records on file indicating
whether the system component is H-10 or H-20),the system shall also be deemed as a
"conditional pass". In this case,the seller must make the potential buyer(s)aware of the
"conditional pass" status,the unknown construction of the septic system component(s),and it's
safety concerns.
Wayne Miller,M.D. Paul Canniff,D.M.D. Junichi Sawayanagi
C:\Users\Frank\AppData\Local\Packages\Microsoft.MicrosoftEdge_8wekyb3d8bbwe\TempState\Downloads\HI OComponentsBeneat
hDriveways&ParkingAreasRevised2013(1).doc
Thomas McKean <thomas.mckean@town.barnstable.ma.us> 7/29/2020 4:48 PM
698 Shootflying Hill Road, Centerville Massachusetts
To titlefive@comcast.net<titlefive@comcast.net> Copy David Stanton <david.stanton@town.barnstable.ma.us>
Good Afternoon Mr.Nunes„
I understand there are two block cesspools located beneath the driveway at 698 Shootflying Hill Road,
Centerville,Massachusetts. You stated on the telephone today that the cesspools are functional,they appear to be
in good condition without any signs of collapse,and there are no signs of loss of structural integrity. As you
indicated,cesspools were not designed by professional engineers back then(more than 50 years ago) so the
loading ratings of cesspools were not noted nor provided.
Based on the information you provided to me on the telephone today,this functional cesspool system would
"pass"a real estate transfer septic system inspection in some towns-due to the fact that it meets the passing
standards contained within the State Environmental Code Title V.
However on October 9 2012,the Town of Barnstable Board of Health adopted a policy regarding components
beneath driveways(see attachment). Whenever the loading rating of a septic system component beneath a
driveway is unknown,the Board of Health policy requires the inspection report to be marked as"conditional
pass." Also in accordance with this policy,the seller must make the potential buyer aware of the"conditional
pass" status and the unknown loading rating of the cesspools.
I hope this information is helpful.
Sincerely,
Thomas McKean
• H10ComponentsBeneathDriveways&ParkingAreasRevised2013.doc(67 KB)
McKean, Thomas
From: McKean, Thomas
Sent: Wednesday,July 29, 2020 4:48 PM
To: 'titlefive@comcast.net'
Cc: Stanton, David
Subject: 698 Shootflying Hill Road, Centerville Massachusetts
Attachments: H 10ComponentsBeneathDriveways&ParkingAreasRevised2013.doc
Good Afternoon Mr.Nunes„
I understand there are two block cesspools located beneath the driveway at 698 Shootflying Hill Road, Centerville,
Massachusetts. You stated on the telephone today that the cesspools are functional,they appear to be in good condition
without any signs of collapse, and there are no signs of loss of structural integrity. As you indicated, cesspools were not
designed by professional engineers back then (more than 50 years ago) so the loading ratings of cesspools were not noted
nor provided.
Based on the information you provided to me on the telephone today,this functional cesspool system would"pass"a real
estate transfer septic system inspection in some towns- due to the fact that it meets the passing standards contained
within the State Environmental Code Title V.
However on October 9 2012, the Town of Barnstable Board of Health adopted a policy regarding components beneath
driveways (see attachment). Whenever the loading rating of a septic system component beneath a driveway is unknown,
the Board of Health policy requires the inspection report to be marked as"conditional pass." Also in accordance with
this policy,the seller must make the potential buyer aware of the "conditional pass" status and the unknown loading
rating of the cesspools.
I hope this information is helpful.
Sincerely,
Thomas McKean
1
r r V
Commonwealth of Massachusetts ,r
Executive Office of Environmental Affairs
• �6�f �g�0��o1 �
M111am F.Wold $e N
Argeo Paul Callucal ® stru
u.eavarmw
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 6`f '�Sd�cT �)1leaO 00- �l�Address of Owner. y�'c�rn:c� G�n�i�ct.?
Date of Me son: \-t-ajr vu Ay /5
, ry
Nance of Inspector: ee,r-o I y,7 7, 91,y/F, � -4
Company Name, Address and Telephone Number: C J Engineering
48 Gully Lane
Sandwich MA 02563
CERTIFICATION STATEMENT Phone/Fax(508)888-4975
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the pro 9I and
maintenance of on-site sewage disposal systems. The system: Ltd OF
Passes CAROLYN
r*�
Conditionally Passes ® J. —'
Needs Further Evaluation By the Local Approving Authority DOYLE
-® No.34531
,.Fails se
® �O,r STl:���
Ibtas@ar'$ 5i�rta4tare: L Date: fl�`1 G""t�.t y !S I%C' �SSrONAI
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of complet is
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 su&mit
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, B, C, or D:
A] ,SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why noo
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 11/03/95) 1
One VAntcr Ltr®at a Louton, Masarchusattz 02108 a FAX(617)556-1049 a Telephone(617)292-55Q0
ce
�a4 Printed on Recxkd Paper
"l
Q"1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: (�4�' S vo7-G'/f-.iy 11ii/
Owner: E Qe�/ce CooGrincu.�
Dyatte,�f 1 nsped�,ont i
B] SYSTEM`CON DITIONALLY=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):
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 protest the
public health, safety and the environment.
1) SYSTEM Wii LL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT TIME 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 VALL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DEYEr;BMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMINT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ Tha system has a septic tank and soil absorption system and 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
fry from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
Fes-
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:. 8enoiLC Gocr �i�r�7
Date of Inspection:
D] SYSTEM FAILS:
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.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
ge yr rviviii'g of effluento the u f f the ground or s-Xf3ce waters clue to an overloaded or cloned S.A.S.or
t., • s.:. ace o�
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 sttpply.
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:
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 dneat to
public health and safety and the environment because one or more of the following conditions exist:
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 program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
r,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: &If 5/roo7- ZI XV
Owner:
Date of.Inspection:
Check if the following have been done:
tS /graldv r
Pumping information was requested of the owner, oeeapent, and Beafd-e¢•++ea .
one 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.
kW As built plans have been obtained and examined. Note if they are not available with N/A.
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.
✓/ i�cict�i.r
All system components, the Soil Absorption System, have been located on the site.
/The se Ccptile manholes were uncovered, opened, and the interior of the . k 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 existing information or
approximated by non-intrusive methods.
vfThe facility owner(and occupants, if different from 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: (c�lb' i��a� TF/...� 11i11/�V,
Owner:
Date of Inspection:` Y 1S1- 19417
FLOW CONDITIONS
RESIDENTIAL:
Design flow: `3.3 O gallons
Number of bedrooms:-_
Number of current residents: 67 (CULL - Orly yrr�ctii�7")
Garbage grinder(yes or no):_d 0
Laundry connected to system (yes or no): /DES
Seasonal use(yes or no):_,s �e co nc��?G'�e✓
,ii Water meter readings, if available:
Last date of occupancy:
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) 1.,;10
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
t/ Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if,yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 [ai/7-1-rl /a 70'5
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address
Owner.
Date of Inspection: cr
SEFrnC TANEC:,L/,�
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain) —-
Dimensions:
Sludge depth: —
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: ,concrete _metal —FRP —other(explain)
Dimensions:
Scum thkkrmss:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to,outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S,17aeo
Owner: 4'1'-1Y!1'c e 00�-`irli.7
Date of Inspection:
TIGHT OR HOLDING TANK: AIW-
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions: ,
Capacity: gallons
Design flow: galions/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTWOUTION BOX:��
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_� f}
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
P I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6 q6' -51 F/f.�hy 117/!'14W,
Owner: d e'r`n i c e G -7
Date of Inspection: S u,cY /S /�/y;
SOIL ABSORPTION SYSTEM (SAS): See C essl,,o/ belt-,W
(locate on site plan, if possible; excavation not 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:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Doh-top of liquid to inlet invert: !� —5nou!/�"&Zle l—a-� Z/V o f' e'PsS�oo J
Depth of solids layer. .y/f_y� (72i.IP?S f lcsl��✓f/rtc�rO
Depth of scum layer: N/4
Dimensions of cesspool: 6ldi inure re P- K 6'ef�ecn�t C./e/✓j�lj
Materials of construction: LonCi-e7`e blOcl<
Indication of groundwater: acwe
inflow(cesspool must be pumped as part of inspection) lPs:4Aod/ wv 7- ,<fyv .0e2e'
P!i`Y PHl� !J/7>V✓Y rJc! f' Gtt bn � c� r'PSS .!J,r7ir ___--
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
d fa v_ L if /'-_5 `i o rJ el/JEl T O Gc>P
7� �i--lie a 'vPr 7�;s s�-vc77�r�/ GusT ���• r�/ef-Te@ T:��oc�Go��'no�
PRIVY:
(locate.on site plan)
Materials of consmx:tion: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition-of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (cR j' Shoo T
Date of Inspection: -�avGf1
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' �ve�Ua Q ve-7-
- La ices,
U
J
tagVL
�` �riY� ri✓Cr r � �— ----
Sir i"vital ��T he q//o twe-cl �-V
DEPTH TO GROUNDWATER
Depth to groundwater. 20t feet
method of determination or approximation: Va, C��e//LrP4c� l�it�7�'C7�o.� � �4.�fil��l. ter/-Dd�G�u��r7c'r
(revised 11/03/95) 9
TOWN OF BARNSTABLE
LOCATION ,6 '}
�b�� � 111�/ / ;' SEWAGE #
VILLAGE L'Pih �.r Vi J� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. �
SEPTIC TANK CAPACITY le
LEACHING FACILITY:(type) (size
NO. OF BEDROOMS- _PRIVATE WELL OR PUBLIC WATER I , be,,-,
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�,
', �
��
M
1