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Home My WebLink About0727 SHOOTFLYING HILL RD - Health 727 SFiootflying Hill Road A = 192- 081 Centerville S M EAdD II Na 63LOR UPC 12543 smead.com • Made tn USA 4 ?m). ' �: {��0M��VV�� /� �� ~/�/ �� ~��0�� ~��~��^��W ��~��~�� 0�� « l 41 mn �� '�� 0 ��mmU Inspection �� e,�� nm ��muom Subsurface Sewage Disposal System Form Not for Voluntary Assessments 727SHDDTFLY|NG HILL R Property Address PETER NAGORKA Owner Owner's Name information is equieU�ree� �ENTERy|LLE 5/1�2O21 page. City/TownS,p�--' --- ------------------------ Zip Code Date vfInspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist mt the end of the form. Important:When A. 0�� nmn8out�nns ^^^ Inspector~ n xu"vonxux"wtnonn |is°fo °_ on the computer, use only the tab Trovor &eUett key m move your Name'xInspector � cursor do not qaje Cod 5 U Services � use the return xcv. Company Name 35O Main St. Company Address VVYarmouth MA 02673CitylTown State Zip Code 508'775'2825 S|'13744 Telephone Number License Number EK Certification | certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CK8R 15.000)| | have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, ouuureba 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 ofon'oito sewage disposal systems. After conducting this inspection | have determined that the system: 1. Z Passes 2. El Conditionally Passes 3. |\ Needs Further Evaluation by the Local Approving Authority 4. El Fails —~� 5/25/2021 inspector's Signature Ya�e____ 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 f| 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 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. ��p.*oc'rev.n26ovm Title 5 Official Inspection Form:Subsurface sewage Disposal system'page 1mm Commonwealth of Massachusetts Title 5 Official Inspection Form 1 = r! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 p Y y 727 SHOOTFLYING HILL RD Property Address i ---.--_-------- — PETER NAGOR_KA____ Owner Owner's Name information is required for every CENTERVILLE MA 02632 5/18/2021 --------------------_----__-------__--_____.__. ------ —.....-------- -- -- -- page. City/Town 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: ® 1 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: SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: One or mores stem components ponents as described in the "Conditional Pass section ton 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): t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Forin:Subsurface Sewage Disposal System•Page 2 of 18 ex L Commonwealth of Massachusetts ,Z I `title 5 Official Inspection Form �, - _. I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD Property Address - PETER NAGORKA Owner Owner's Name -- `— information is required for every CENTERVILLE _ _ _ MA 02632 5/18/2021 page. City/Town 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 S Official Inspection Form:Subsurface Sewage Disposal •System Page 3 of 18 Y 9 Commonwealth of Massachusetts � - Y Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHO_OTFL_Y_ING HILL RD Property Address --------------- --- --------- --- — -- PETER NAGORKA ------ ----— --------- .-------------- ----- OwnerOwner's Name -------- information is CENTERVILLE MA 02632 5/18/2021 required for every ------ -- ---- ---------- -- -- ----- — --- — --- page. City/Town 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.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts w7 Title 5 Official Inspection Form 1 ^ l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD Property Address T PETER NAGORKA Owner Owner's Name information is CENT_ERVILL_E _ _ MA 02632 5/18/2021 required for every _ _ _ 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 '/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 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 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. 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 l5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form U� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SH_OOT_FLYING_ HILL RD Property Address PETER NAGORKA _ Owner Owner's Name — information is CENTERVILLE MA 02632 5/18/2021 requiredd for every ----------,.------- --------------------- --- ---- -------- — _ page. City/Town 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 ffieiel Inspection Form l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD Property Address PETER NAGORK_A_ Owner Owner's Name — —information required is CENTERVILLE MA 02632 5/18/2021 required for every -. --- ----------- - --------- ----.--- ---- --- - page. C t-y/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4---- Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 440 _ Description: Number of current residents: 1 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): '20-96 GPD '19 -85 GPD Detail: - Sump pump? ® Yes ❑ No Last date of occupancy: CURRENT Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 `ff icial Inspection Form rs Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address PETER NAGORKA Owner Owner's Name information is required for every CENTERVILLE MA page. City/Town State Zip Code Date of Inspection -- D, System Information /coDf.\ 2. Commercial/industrial Flow Conditions: Type ofEatab|iehment Oaskgn flow (based on 310CK8R 15203), Gallons per day(gpd) Basis of design flow rouno/so.ft. ebz \: Grease trap present? 0 Yes 0 No Water treatment unit present? El Yes El NO |f yes, discharges to: � Industrial waste holding tank present? El Yes D No Non-sanitary waste discharged to the Title 5system? El Yes 0 No Water meter readings, if available: .Last date ofuooupanoy/usa: --' Other (describe be|ow): ` 3. Pumping Records: N/A Source ofinformation: Was system pumped aopart of the inspection? El Yes Z No |f yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ----- t5i"�um'rev.nz6120,o Title o Official inspection Form:Subsurface Sewage Disposal System'Page em,o U U Commonwealth of Massachusetts T -de 5 Official Inspection Form it Subsurface sewage Disposal System Form Not for Voluntary Assessments Property Address PETER NAGORKA Owner Owner's Name information is �qu�dkx�e� CENTERV|LLE page. C.v".ow/ State Zip Code Date ofInspection � SystemD. -- - `---' 4. Type ofSystem: Septic tank, distribution box, soil absorption system L] Single cesspool �] Overflow cesspool U Privy El Shared system (yes or no) (if yes, attach 'previous inspection records, if any) LJ Innovative/Alternative technology. Attach a copy of the current operation and ' maintenance contract (to be obtained from system owner) and a copy nflatest inspection of the |/4 system by system operator under contract � El Tight tank. Attach a copy of the DEPapproval. El Other(describe): Approximate age of ail components, date installed (if known) and source of information: 2008 PER PLAN ON FILE AT 8OH �� Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: El cast iron 0 40 PVC other (explain): Distance from private water supply well or suction line: -10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED (5insp doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments tY .: ... 72_7 SHOOTF_LYING HILL RD '- Property Address ----------- --_--- -- - PETER NAG_0__R_KA_ Owner Owner's Name — -- information is CENTERVILLE MA 02632 5/18/2021 required for every ---- --------- ------ -_.._.... - -- - — --- /2021 — -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. 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: 1000 GALLON Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle — Scum thickness 2"- 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? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 11" BELOW GRADE l5insp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 ' Commonwealth of Massachusetts _ �, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOO_T_FLYING HILL RD Property Address --------- -------�--J — - PETER NAGORKA Owner -------- -----.__----- Owner's Name — - -- ion is reequiredquired CE for every ----NTERVILLE MA 02632 _ 5/18/2021 _--------------------_--------------------- ----------- - --- —. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: Beet — 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 188 Commonwealth of Massachusetts Title 5 Official Inspection For i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD Property Address PETER NAGORKA Owner "Owner's Name --—- -- -- -- --- --------- information is CENTERVILLE MA 02632 5/18/2021 required for every -----------_._.____._._.._.._._.___...----__-- ----.-- --- - page. City/Town 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: pate 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any. evidence of leakage into or out of box, etc.): DISTRIBUTION BOX LEVEL AND WATERTIGHT. SPEED LEVELERS IN PLACE t5lnsp doc•rev 7/26/201 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For - i'I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 S_H_O_O_TFLYING HILL RD . . Property Address ------------------------------- ---- - -- PETER NAGORKA Owner Owner's Name information is required for every CENTERVILLE __ _ _ _ MA_ 02632 _ 5/18/2_021 _ _ _ page. City/Town 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: 3-500 GALLON— ❑ leaching galleries number: — ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ----- ❑ overflow cesspool number: -- - ❑ innovative/alternative system Type/name of technology: -- --- ----- - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts fs Title 5 Official Inspection Form -- I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD - � Property Address --------------------------- --- -- PETER NAG_O_RKA_ Owner Owner's Name information is CENTERVILLE MA 02632 5/18/2021 requiredfor every --_.-_------------._._-_..__...__..__--------_---------.__-_..- ---_..---__-- -------__-____ page. City/Town 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.): 3-500 GALLON CHAMBERS WITH 4' OF STONE FOUND WITH 1" OF EFFLUENT DURING INSPECTION WITH NO EVIDENT STAINING. 12. 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 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 14 of 18 Commonwealth of Massachusetts `title 5 Official Inspection For Disposal Sewage Subsurface p y g Dis System Form Not for Voluntary Assessments cat 727 SHOOTFLYING HILL RD Property Address — PETER NA_GORKA Owner Owner's Name---- -- ---— ----- ------— — ---------— information is required for every CENTE_R_VILLE _ MA _ 02632 _ 5/18/20_21__ _ _ 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.cloc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts `title 5 Official lnspect on Form - �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD Property Address -- ---•- PETER NAGORKA -__----- --_-_.._... --...._ -- .... _.._...—_.._...._ _------- ...---..---..__--..._...------ Owner Owne.--r's Name-- --- information is CENTERV requiredd ILLE for every --....._.._......... .. _.. ._..----------.-.--.---.._.__..__...... MA_._._._ 02632 5/18/2021 _ page. City/Town _._ip-_.._—__........._.. Inspection _ — — State Zip Code Date of Inspection D. m 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 1 _ 4 h N.z 1 i - 4 t5lnsp.doc•rev.71261-M a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD Property Address PETER NAGORKA Owner Owner's Name information is required for every -CENTERVILLE MA 02632 5/18/2021 -._... -----------------._...__—_-------------- ------ ----- — -- — page. City/Town 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: ±1feet — 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: 4/4/08 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) Checked with - ❑ t 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: TEST HOLE DATA PER PLAN ON FILE AT BOH SHOWS NO GROUNDWATER AT 12'. HAND AUGER PERFORMED ONSITE AT TIME OF INSPECTION TO 13' ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 6' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp ooc•rev 72812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For � `'I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 727 SHOOTFLYING HILL RD Property Address PETER NAGORKA Owner Owner's Name— - ---------------- ------ -information is CENTERVILLE MA 02632 5/18/2021 required for every - -------- ---- --------- - -- --- ---....--- —8/2021 -- page. City/Town " 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 (51nsp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 � ✓✓ >� o �� f / f No. ..--- --~ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in com ter: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 1 appiitation for ]Disposal Opstem Construction Vertu Application for a Permit to Construct( ) Repair Upgrade Abandon( ) ElComplete System RInodividual Components Location Address or Lot No. 7z, YI I�1Lt-W caner s N e s,A dr elNo.Assessor's Map/Parcel �9 Installer's Name Address,and�TTom�.No. Designer's Name,Address,and Tel.No. /1W44� -4S A TinwN�C �9 M 7ZS 2- AN�✓/�/ GAS 67t/!r jWe, 93P&P14N Sr' 2 Type of Building: Dwelling No.of Bedrooms 4- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) #44c gpd Design flow provided SS gpd Plan Date A ARRA 2m*8 Number of sheets Revision Date Title T/TLE V Sj IX AMAme OF 7 27%/ ' N�AWL AQ &OZ "A Size of Septic Tank DOO Type of S.A.S. MELT Description of Soil Cj jpAC 1 Nature of Repairs or Alterations(Answer when applicable) DISC: p Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issu4by Boar f alt (3 Date LO NOVO Application Approved by Date Application Disapproved Date for the following reasons Permit No. _ Date Issued VNrO o. 97 1 c' t f'\� Fee ,. THE COMMONWEALTH OF MASSACHUSETTS Entered inc0 ter: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppIication for Misposar Opstetn Construction J)ermit Application for a Permit to Construct( ) Repair Upgrade�) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. '7Z o oyT� Y1 r J4-Wit Owner's Name,Addre s,,an d,Tel.No. � Assessor's lvlap/Parce,eGAD ��ikrQ CAa-Q/s / / Installer's Name,Address,and Te.No. Designer's Name,Address,and Tel.No. N/ oLAS A T�-N6De 989 72,.S2- 004-l" C.,+�L 67V& PvC 932 A-7AvN 5T 2 K4em lo4 Oz.t. 2 Pat ,A 526 Type of Building: Dwelling No.of Bedrooms 4— Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A 4O gpd Design flow provided SS gpd Plan Date 4 4PZI/ ? oP Number of sheets_/ Revision Date Title J1TLF V S!17= AL_dn1 Of 7 27<Z=��YanA 4 c//LL �Q _174 J /Y!4 Size of Septic Tank 10Uo Type of S.A.S. LEN" t T_t � Description of Soil C LASS 1 Nature of Repairs or Alterations(Answer when applicable) D j,�+. Date last inspected: Agreement: - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar f Health Sig ed �' L' Date /0 Al v Z 0 Application Approved by ; Date ApplicationiDisapproved by Date for the following reasons Permit No. Date Issued ------.------------------------------------------------ - ---------------- ----=- --_- - ---_-- ---==------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERtTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Y Upgraded( ) Abandoned( ) at r �'� as b en cons 2te"iac ewith the provisions of Title 5 and the for Disposal System Construction Permit No. ted Installer 1 Designer #bedrooms Approved design flow r �j gpd The issuance of thi permit li n not be construed as a guarantee that the system will ncf on as designed. Date Inspector - - - - - -- - No. Fee "— / THE r COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION IBARNSTABLE,MASSACHUSETTS = Misposal Opsteut Constructio ermit Permission is hereby granted tp Construct( ) Repair( ) Upgrade(l/ Abando System located at c�•• L �J�/�Z. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constru ti n mu be pleted within three years of the date of this permit. Date Approved by 4{ a Y 035 Town ®f Barnstable eb®ZINC� � Regulatory Services Thomas F. Geffen, Director * ]BAR vsrasLE, HASS. Publfe Health Division 'Thomas McKean, Director 200 Main Street,Hyannis,PV[A 02601 Office: 508-862-4644 Fax: 508-790-6304 InstaHerr & Desi2mer Certifleation Form Date: /� a y �� Sewage Permit# Assessor's MapTarccell Designer: C�I 2 EYAO i r)ee nr`$' Inns>ta ler<°: m-t e-a ZAS TdNNpZ, n Address: � 1R) �-- Address: FP BOY V17 a^/M o,'-9, 5.YA¢wro rJTU M A 0741, 7 On 11 l f 0$ N rG N IJUL was issued a permit to install a —r(date) r7 (�/ installer) septic system at /°�7 U l�0 U fffl I rl ��rr l7� � � rl based on a design drawn by a dres ) ct, e f,Ja dated (desi r) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. H OF MgSsgti DANIELA. c�N (Installer's Signature) o OJALA CIVIL -o No,46502 ` ox,F S�rN A L NG\�� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC; HEALTH DMSION CERTIFICATE OF CONIF ,AANCE IML NOT BE !SSUED aTN'Il'M BOTH TTt S FORM AND AS-BUILT CARD ARE RECEDED BY TBE BARNSTABLE PUBLIC HEALTH DMSION THANK YOU Q:Health/Septic/Desiguer Certification Form 3-26-04.doc r - TOWN OF BARNSTABLE LOCATION 797 S✓4i "Fiy%NG /4,// Rki ,. SEWAGE# 9008- 1177 VILLAGE CEN raR y I kr ASSESSOR'S MAP&PARCEL i9a -- 18 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /,000 ` LEACHING FACILITY:(type) .�, r- ,�N� C�F "—S'ize) S/Sbo 6AI H-1 p NO. OF BEDROOMS OWNER CigRns `}`kTER L40�s 4 ' ll PERMITDATE: ��-/O-'®� COMPLIANCE �-"" Separation Distance Between the: _ j1/t►T Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility b<01114 TJERAeet Private�Water Supply Well and Leaching Facility(if any wells elk on site or within 200 feet of leaching facility) MWCE feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet w. FURNISHED BY SACS s,Z �.\ °F THE Town of Barnstable Barnstable �M .T°�y°- Regulatory Services Department e'caC"y I, BARNS-MLE, , ` " 39, Public Health Division AlFb MAt a. 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO January 2, 2008 Kenwood Lawson P.O. Box 55 Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 727 Shootflying Hill Road, Centerville MA was inspected on October.10, 2007, by Mark Polselli, certified Title V Septic Inspector for the State of Massachusetts. The-inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or-clogged µ SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF HE BOARD OF HEALTH Thomas McKean, R.S., CHO , Agent of the.Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\727 Shootflying Hill Road.doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS b Y m d DEPARTMENT.OF ENVIRONMENTAL PROTECTION e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: / ,S�'/OO I, Owner's Name: ev7 t✓on A ws o h — G/ �0 her Re J O/ A-� Owners Address: p —7 D arreS a � � O 6�0 Date of Inspection: /o /v p Name of Inspector: (please print) a1, 41- Company Name: E (i1 O -- —EG/f Mailing Address: OIL of Telephone Number: s'y 9 — ,;�—�f�}W CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP . approved,system inspector pursuant to Section 15340 of Title 5(310 CAM 15.000). The system: i 3 C'' z Passes Conditionally Passes Y� _ e Further Evaluation by the Local Approving Authority r'' y- ailsC3 Inspector's Signature: . /�G��?/�'4 Date: to /o O ; ' = X:- r- c_: M The system inspector shall sub ' a copy of this inspection report to the Approving Authority(Boar of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design ow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page.1 Page 2 of 11 OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART A /CERTTII�CERTIFICATION(continued) Property Address: �� /�00f7l „ : P Owner: In.1 Date of Inspection: O o Inspection Summary: Check A,B,C,D or E!ALWAYS complete all of Section ID 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not deteri wined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank.as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PANT A CERTIFICATION(continued) Property Address: /oZ/ Jh pp� 14t �11 ��✓ Owner: Gi 1 s Date of Inspection: C. .Further Evaluation is Required by the Board of Health: Al/y Conditions exist which require finther 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 CNM 15303(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 i 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: 1 r 1 1 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP®SAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �00 rh 17r Owner: sue/ Date of Inspection: /o 4o D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes o B ckup 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 tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool 1 c/ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow _ _Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number Qf times pumped _�/Axy 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. _e"Any portion of a cesspool or privy is within a Zone 1 of a public well. __t, P.nyportion of a cesspool or privy is within 50 feet of a private water supply well. r/Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] -P (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of .Health to determine what will be necessary to correct the failure. 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have an ered"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 3 10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �r►��v017 7 /�5 �!/�� /` Owner: Date of Inspection: �Q o Check if the following have been done.You must indicate"yes"or"no"as to each of the following:. Yes No 27,.ny g information was provided by the owner,occupant,or Board of Health of the system components pumped out in the previous two weeks? Y mP , Has the system received normal flows in the previous two week period? c/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? fWas 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? (/he_ 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: Yes no �xisting 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 15302(3)(b)] l ' Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /�/ io0� 7 /,7 / Owner: Date of Inspection: /O 0 0 ` FL W CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):2)-0 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or n601 Seasonal use: (yes or no):14 Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe):. GENERAL INFORMATION Pumping Records / Source of information: Was system pumped as part of the inspection(yes or no):— If yes,volume pumped: gallons--How was quantity pumped determined? Reaso�forg: TYP OF SYSTEM _ Septic tank,distribution box, soil absorption system s�—Single cesspool A-0 _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date e own)and source of information: Were sewage odors detected when arriving at the site(yes or no): Titles G Tno.—+.'--L',._.._. c ii c i1— F i Page 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6—//.40 Owner: i.✓1� Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: / Materials of construction:_ ast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:�� (locate on site plan) Depth below grade: Material of construction:_cow ncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: / Distance from top of sludge to bottom of outlet tee or baffle: f Scum thickness:I'�1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto,f utlet tee or baffle How were dimensions determined:_/ C'�y/ce— Comments(on pumping recommendations,inlet and outlet tee or baffle cgnditon,structural integrity,liquid levels as related to outlet invert,evidence of lea ge,et .): e► ` q �T/!�1 c7�t�t,�, /✓1 GREASE TRAP:Z411ocate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):. '] Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: Shoo Owner: ! wso Date of Inspection: l0 O O 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc): DISTRIBUTION BOX: /!i (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(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM' PART C nn SYSTEM (INFORMATION(continued) Property Address: /a� "POoT7 q in 7�i// 2r� Yvi Owner: o�Irr�l Date of Inspection: 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: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumpe—d.as part of inspection)(locate on site plan) Number and configuration: / Depth—top of liquid to inlet invert ri Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: r11�1 Indication of groundwater inflow(yes or no): Comments(note nditi9n of soil,si pf hydraulic failure,level of pondin ;condition of vegetation,etc.): .i PRIVY: (locate on site plan) Materials of construction: Dimensions: S Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Taal_ l T.__._ Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Owner: l--�wSO vl Date of Inspection: /Oj 9� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Loca te all wells within 100 feet.Locate where public water supply enters the building. EG i in 10 - Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ew � Owner: Date of Inspection: 0 /O _ SITE EXAM Slope Surface water Check cellar Shallow�wells i Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obta' �tem design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole wit ' 150 f of�AS Checked with local Board of.Health-explain: �� Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describ how u established the,high gro}{nd water e1 atio :L.4 HE Town of Barnstable T Tp� Regulatory Services yo Thomas F. Geiler,•Director BARNSTABLE, 9� ' ,0� Public Health .Division AjEp�,�A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with an technical observation s and interpretations� y � contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE i LOCATION *�T 2" i� i :l + SEWAGE # VILLAGE Q,7n�&cu& ASSESSOR'S MAP & LOT I 22—CIO INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO: OF BEDROOMS�. PRIVATE WELL O UBLIC WATER" BUILDER OR OWNER (?,'() dnA a or-, DATE PERMIT ISSUED: DATE •COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No `( _ 14oml,dwA�2 ,: �� 1 (��®+ {� V C � �� 1 SYSTEM- PROFILE NOTES Rd. TOP FNDN. AT EL 77.5' Q°k Street �\\ ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SG ACCESS COVER TO WTHIN 3" OF FIN. DATUM IS APPROXIMATE NGVDN. GRADE ACCESS COVER (WATERTIGHT) TO r 75.9' MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 2. MUNICIPAL WATER IS EXISTING 74.0' � Wequaquet .. 2 DOUBLE WASHED PEASTONE 3.-MINIMUM PIPE PITCH TO BE 1/8" PER 'FOOT. to s Lake 75.1 RUN PIPE LEVEL OR GEOTEXTILE FABRIC EXISTING FOR FIRST 2' ` 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO *#EXISTING 1000 H- 10 Q° . EXISTING GALLON SEPTIC TANK 73.7t 71.0' o 00d GAS �� 70.3' 5. PIPE JOINTS TO BE MADE WATERTIGHT. ` �aK6� pt BAFFLE 70.47 0 ED 0 = O D O O O 70.2' p ED 0 0 0 � 0 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH o �- 6" CRUSHED STONE OR MECHANICAL o O 0 a Q O 0 1� 1 MASS. ENVIRONMENTAL CODE TITLE V. COMPACTION. (15.221 [2]) 2' 0 0 0 ED a o a ED a a 68.2 DEPTH OF FLOW = 4 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO o c TEE SIZES: 3/4" TO 1 1/2„ DOUBLE WASHED STONE BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. `' n ,�ao INLET 'DEPTH = 1L ft OUTLET DEPTH = 14-" (4'•8% SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ( 1 X SLOPE) 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FOUNDATION EXISTING SEPTIC TANK 68' D' BOX 12" LEACHING 5.2 WITHOUT INSPECTION BY BOARD OF HEALTH AND FACILITY PERMISSION OBTAINED FROM BOARD OF HEALTH. LOCUS MAP - SCALE: 1 = ,0 f �- 10. CONTRACTOR SHALL BE RESPONSIBLE FOR -CALLING *THE INSTALLER SHALL VERIFY THE - "'_.�**THE INSTALLER SHALL CONFIRM MIN. "�� DIGSAFE (1-888-344-7233) AND- VERIFYING THE LOCATION ASSESSORS MAP t92 PARCEL 18 LOCATIONS OF ALL UTILITIES AND ALL SEPTIC TANK SIZE AT 1000 GALLONS AND BOTTOM TH-2 ,EL. 63.0'� OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY TOR RE-USE COMMENCEMENT OF WORK. PRIOR TO INSTALLING ANY PORTION OF LOCUS IS- WITHIN AP. OVERLAY DISTRICT SEPTIC SYSTEM __--'' -� 11. EXISTING- LEACHING FACILITY SHALL BE PUMPED AND ``--___.._.....___..._. _._._. - - ----"`✓ ALL SYSTEM COMPONENTS SHALL BE REMOVED OR PUMPED AND FILLED WITH CLEAN. SAND. MARKED WITH MAGNETIC TAPE OR COMPARABLE MEANS FOR FUTURE LOCATION. 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND- THE--PROPOSED LEACHING- FACILITY. LEGEND 100.0 PROPOSED SPOT ELEVATION SYSTEM - DESIGN: GARBAGE DISPOSER- IS NOT ALLOWED +100.00 EXISTING SPOT ELEVATION 111.94' 100 ,�� -�� - I DESIGN FLOW: 4 BEDROOMS ® 110 GPD 440 GPD o PROPOSED CONTOUR I 34• ' A USE A 440 GPD DESIGN FLOW 100 EXISTING CONTOUR " LOT 2 TH-2 OOX RESER 24,837t SF ;_ . • .�.. .�= II SEPTIC TANK: 440 GPD (2) 880 0.6t AC. "` 10.4' TH-4 TH-3 **RE-USE EXISTING 1000 GAL. SEPTIC .TANK BENCH MARK - CORNER CONC.L I LEACHING: BULKHEAD ELEV. 76.5 TEST�+ 1 E�7T DOLE LOGS = ' _ - C SIDES: 2 (33.5 + 12.83) 2 (.74) = 137 GPD I 40 SHED �h I O BOTTOM 33.5 x 12.83 (.74) = 318 GPD ENGINEER: DAVID FLAHERTY,R.S:,.-SE2755 i p TOTAL: 6t 5 S.F. 455"GPD WITNESS: DONNA MIORANDI, R.S. DATE:- MARCH 6, 2008 (1&2), APRIL 4, 2008 (3. & 4) . I I USE (3) 500 GAL-. LEACHING CHAMBERS (ACME OR EQUAL) WITH . 4'. STONE ALL AROUND PERC.' RATE __. < 2 MIN/INCH _ I ^,, 10 I CLASS I SOILS P# 12118 I 2 eR A .� P ° TOP OF flDN o I `� a. 77s' 40 o ELEV. ELEV. ELEV. ELEV. o I DECK o I MA o 04 APPROVED DATE BOARD OF HEALTH p" 4 74.0' p„ 74.0' 0" 74.0' 0" `!ir' 74.0' N. I. wO A A A A '4 LS LS LS LS I ( y PAVED DRIVE 10YR 4/2 10YR 4/2 10YR 4/2 10YR 4/2 - 4" 4„ 4„ 8„ TITLE 5 SITE PLAN B B B B I OF LS LS LS LS 'S „ 10YR 5/6 , " 10YR 5/6 „ . 10YR 5/6 10YR 5/6 , \ I I 727 . SHOOTI=LYING . HILL RD. 30 71.5 32 71.3 24 72.0 27 71.7 I � I -x x '4 py (CENTERVILLE) BARNSTABLE, MA ,2 GAR. . PREPARED FOR C C C C ,. PERC-.. _ PERC H �i a M. RRIS & PETER LAWS ON- MCS MCS MCS MCS es ANIELAgc �v J�c� o�' ti�• o DANIEL 6s � N� q " DATE: MARCH 8, 2008 o OJALA :, 67 " CIVIL N REV. DATE: APRIL 4, 2008 (ADDN. TH S) k 10YR 7/4 tOYR 7/4 10YR 7/4 10YR 7/4 6 6.0 09 -o '� 0' N .4 980� 1 , off 508-362-4541 113.91 N QF f ��QFvny s fax 508 362-9880 DANIELA. ti� �° DANIEL �rn „ „ -=-- „ , OJALA A. down cape en gin eerin g, inc. 120 64.0 132 63.0 120 64.0 120 64.0 CIVIL Flo.465fl2 6 ' o.40 S, Cl 1//C ENGINE NO GROUNDWATER ENCOUNTERED J7 , NO GROUNDWATER ENCOUNTERED Scale:l"= 3C' '�oIST �`'P LAND SURVEYORS cNG �SUR�ti� 939 Main Street - YARMOUTHPOR.T, MASS. 0 15 30 45 60 75 FEET DATE DANIEL A. LA, P.E., P.L. . DGE #08-035 08-035 LAWS ON.DWG (DDF)