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HomeMy WebLinkAboutKNIGHTS INN (FORMERLY "CRAIGVILLE MOTEL") - HOTELS/MOTELS j KNIGHTS INN (formerly "Craigville Motel' i THE Town of Barnstable MAW Board of Health 200 Main Street, Hyannis MA 02601 Paul J.Canniff,D.M.D. Office: 508-862-4644 Donald A.Guadagnoli,M.D. FAX: 508-790-6304 John T.Norman F.P.(Tom)Lee,Alternate January 27, 2019 Mr. Dilip Patel Knights Inn/Craigville Motel 8 Shootflying Hill Road Centerville, MA 02632 RE NQTICEOF SHOW CAUSEHEARING Violat,,on.of A eemeri gi t Dear Mr. Patel: You are scheduled to appear before the Board of Health on Tuesday, February 26, 2019 at 3.00 p.m. at the Barnstable Town Hall, in the second floor Hearing Room, 367 Main Street, Hyannis, for a Show-Cause Hearing. This hearing will be held to provide you an opportunity to show-cause why your motel permit should not be suspended or revoked due to your failure to uphold the Settlement Agreement dated October 24, 2016 with regard to ensuring customers do not stay more than 30 days, and in regard to following procedures established to ensure this does not happen. During the inspection of January 24, 2019,violations of three customers who had stayed longer than 30 days were found on the register: (1) James Brown stayed 80 nights from October 9, 2018 to January 5, 2019, (2) Jimmy Crowson stayed 31 consecutive nights from September 2, 2018 through October 10, 2018, and (3)Nicho,Nicolas,Nick, Chuck Nicolas—multiple entries of these names without any identification records (no picture ID,no address); this person stayed in the same Room#132 multiple dates from September 17, 2018 to January 4, 2019 for a total of 34 nights. These violations were noted by Health Inspector Donna Miorandi, R.S. and Thomas McKean, Director. During this hearing, you will have an opportunity to be heard,present witnesses, and provide documentary evidence pertinent to this case. PER ORDER OF THE BOARD OF HEALTH Thom s cKean Agent for the Board of Health Q:\Order letters\SHOW CAUSE Letters and Samples\Knights Inn-Craigvill Motel ShowC FEB 262019.doc Miorandi, Donna From: McLaughlin, Charles Sent: Wednesday,January 9, 2019 10:22 AM To: Miorandi, Donna; Crocker, Sharon Cc: McKean, Thomas;Anderson, Robin;Tripp,Vanessa; dpaananen@westbarnstablefire.com';Weil, Ruth Subject: RE: Knights Inn Attachments: Craigville Motel settlement draft Connors 102016 final.doc Thanks, Donna. There is nothing in the settlement agreement that prevents this woman from standing in for the Patel's who are and will remain ultimately responsible for full compliance with the terms of the agreement. I would suggest that, since the terms of the agreement are quite specific, "Helen" meet with you (and the Patel's, if available) so that you can have her review the terms of the agreement and especially those that affect day-to-day management. I have attached the agreement in case you don't have one. Of course,call with any questions. Thanks. Charlie From: Miorandi, Donna Sent: Wednesday, January 09, 2019 9:12 AM To: Crocker, Sharon Cc: McKean, Thomas; Anderson, Robin; McLaughlin, Charles; Tripp,Vanessa; 'dpaananen@westbarnstablefire.com' Subject, Knights Inn Good Morning: Just an FYI that Dilip Patel of the Knights Inn came in this morning regarding his January 22, 2019 BOH hearing and he informed me that he is on vacation from Jan. 11th until Feb. 1". Both he and Tara Patel will be out of country. To my point, they have hired a woman named Helen (508-280-3458)who will be running the place for the 3 weeks. Is this approved or any violation of the settlement agreement? I have informed Dilip that he will be on the agenda for the February 26th BOH hearing. Dilip's number is 508-292-5728. Donna Miorandi 1 Miorandi, Donna From: McLaughlin, Charles Sent: Monday, January 7, 2019 9:50 AM To: Miorandi, Donna Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Follow Up Flag: Follow up Flag Status: Flagged Thanks, Donna. Let me know if you need anything. Charlie From: Miorandi, Donna Sent: Monday, January 07, 2019 9:45 AM To: McLaughlin, Charles Cc: McKean,Thomas; Tripp,Vanessa; 'dpaananen@westbarnstablefire.com' Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Thanks Charlie for your response. As of now Building and Fire Dept. have signed off on their motel license-it just needs my signature and it is a BOH issue so again I am holding their license awaiting a response from Tom and BOH. Thanks! Donna From: McLaughlin, Charles Sent: Monday, January 7, 2019 9:33 AM To: Miorandi, Donna; Tripp,Vanessa; McKean, Thomas Cc: Anderson, Robin; Florence, Brian; 'dpaananen@westbarnstablefire.com'; Bowers, Edwin; Gallant, Therese; Weil, Ruth Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Thanks, Donna, I would defer to Deputy Chief Paananen and, if he feels it's appropriate, I would recommend bringing this to the attention of the full board and have them make the decision. I suspect,given the operator's history,that the Board would expect full compliance and not game-playing. Certainly a stern warning at a minimum from the full board would be in order if there is game-playing. Charlie r From: Miorandi, Donna Sent: Monday, January 07, 2019 8:39 AM To: Tripp,Vanessa; McKean, Thomas Cc: Anderson, Robin; Florence, Brian; 'dpaananen@westbarnstablefire.com'; McLaughlin, Charles; Bowers, Edwin; Gallant,Therese Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Good Morning: Since it is January 71h and I have not heard back from ANYONE regarding the Dec. 41h email concerning the Knights Inn I am going to sign off on their motel license. Any concerns please respond ASAP. Thanks! 1 Donna Miorandi From:Miorandi, Donna Sent: Tuesday, December 4, 2018 10:00 AM To: Tripp,Vanessa; McKean,Thomas Cc: Anderson, Robin; Florence, Brian; 'dpaananen@westbarnstablefire.com'; McLaughlin, Charles; Bowers, Edwin; Gallant, Therese Subject: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Just an FYI that I may not be able to sign off on their motel license for 2019 based on the Settlement Agreement for their re-opening. At this time it does not appear that their occupants have stayed longer than 30 days. The West Barnstable Fire Department did a spreadsheet based on days and room numbers and it appears that just during Sept. October and November of this year occupants have stayed as much as 21 days. They appear to be playing games flip flopping names for the guest register. This was a great deal of time and work WBFD performed to do this spreadsheet. In addition, they are not consistently photocopying guest drivers' licenses, also part of the settlement agreement. The property appears to have a drainage issue on a very rainy day. On November 13, 2018 Deputy Paananen and myself observed much water in the lot coming up over the curbing and standing at the entrance to the motel rooms. We measured the water in areas to be as much as 3 inches deep. Finally, I checked in with Officer Therese Gallant of the Barnstable Police Department, as requested,for any calls to this property for criminal activity. There appears to be none. I await the final decision. Thank you for your time in this matter. Donna Miorandi 2 Miorandi, Donna From: McKean,Thomas Sent: Monday, January 7, 2019 9:53 AM To: Miorandi, Donna; McLaughlin, Charles Cc: Tripp,Vanessa; 'dpaananen@westbarnstablefire.com' Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Follow Up Flag: Follow up Flag Status: Flagged Thanks Charlie. I agree with your suggestions. It should go before the Board of Health . From: Miorandi, Donna Sent: Monday, January 07, 2019 9:45 AM To: McLaughlin, Charles Cc: McKean, Thomas; Tripp,Vanessa; 'dpaananen@westbarnstablefire.com' Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Thanks Charlie for your response. As of now Building and Fire Dept. have signed off on their motel license-it just needs my signature and it is a BOH issue so again I am holding their license awaiting a response from Tom and BOH. Thanks! Donna From: McLaughlin, Charles Sent: Monday, January 7, 2019 9:33 AM To: Miorandi, Donna; Tripp,Vanessa; McKean,Thomas Cc: Anderson, Robin; Florence, Brian; 'dpaananen@westbarnstablefire.com'; Bowers, Edwin; Gallant, Therese; Weil, Ruth Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Thanks, Donna, I would defer to Deputy Chief Paananen and, if he feels it's appropriate, I would recommend bringing this to the attention of the full board and have them make the decision. I suspect,given the operator's history,that the Board would expect full compliance and not game-playing. Certainly a stern warning at a minimum from the full board would be in order if there is game-playing. Charlie From: Miorandi, Donna Sent: Monday, January 07, 2019 8:39 AM To:Tripp,Vanessa; McKean,Thomas Cc: Anderson, Robin; Florence, Brian; 'dpaananen@westbarnstablefire.com'; McLaughlin, Charles; Bowers, Edwin; Gallant,Therese Subject: RE: Knights Inn, 8 Shootflying Hill Road, Centerville (WBFD district) Good Morning: Since it is January 7tn and I have not heard back from ANYONE regarding the Dec. 41"email concerning the Knights Inn I am going to sign off on their motel license. Any concerns please respond ASAP. 1 ! Thanks! Donna Miorandi From: Miorandi, Donna Sent: Tuesday, December 4, 2018 10:00 AM To: Tripp,Vanessa; McKean, Thomas Cc: Anderson, Robin; Florence, Brian; 'dpaananen@westbarnstablefire.com'; McLaughlin, Charles; Bowers, Edwin; Gallant,Therese Subject: Knights Inn, 8 Shootflying Hill Road, Centerville(WBFD district) Just an FYI that I may not be able to sign off on their motel license for 2019 based on the Settlement Agreement for their re-opening. At this time it does not appear that their occupants have stayed longer than 30 days. The West Barnstable Fire Department did a spreadsheet based on days and room numbers and it appears that just during Sept. October and November of this year occupants have stayed as much as 21 days. They appear to be playing games flip flopping names for the guest register. This was a great deal of time and work WBFD performed to do this spreadsheet. In addition, they are not consistently photocopying guest drivers' licenses, also part of the settlement agreement. The property appears to have a drainage issue on a very rainy day. On November 13, 2018 Deputy Paananen and myself observed much water in the lot coming up over the curbing and standing at the entrance to the motel rooms. We measured the water in areas to be as much as 3 inches deep. Finally, I checked in with Officer Therese Gallant of the Barnstable Police Department, as requested, for any calls to this property for criminal activity. There appears to be none. I await the final decision. Thank you for your time in this matter. Donna Miorandi 2 Miorandi, Donna From: McLaughlin, Charles Sent: Wednesday,January 9, 2019 10:22 AM To: Miorandi, Donna; Crocker, Sharon Cc: McKean,Thomas;Anderson, Robin;Tripp,Vanessa; 'dpaananen@westbarnstablefire.com';Weil, Ruth Subject: RE: Knights Inn Attachments: Craigville Motel settlement draft Connors 102016 final.doc Thanks, Donna. There is nothing in the settlement agreement that prevents this woman from standing in for the Patel's who are and will remain ultimately responsible for full compliance with the terms of the agreement. I would suggest that, since the terms of the agreement are quite specific, "Helen" meet with you (and the Patel's, if available) so that you can have her review the terms of the agreement and especially those that affect day-to-day management. I have attached the agreement in case you don't have one. Of course, call with any questions. Thanks. Charlie From: Miorandi, Donna Sent: Wednesday, January 09, 2019 9:12 AM To: Crocker, Sharon Cc: McKean, Thomas; Anderson, Robin; McLaughlin, Charles; Tripp,Vanessa; 'dpaananen@westbarnstablefire.com' Subject: Knights Inn Good Morning: Just an FYI that Dilip Patel of the Knights Inn came in this morning regarding his January 22, 2019 BOH hearing and he informed me that he is on vacation from Jan. 11th until Feb. 15t. Both he and Tara Patel will be out of country. To my point,they have hired a woman named Helen (508-280-3458)who will be running the place for the 3 weeks. Is this approved or any violation of the settlement agreement? I have informed Dilip that he will be on the agenda for the February 26th BOH hearing. Dilip's number is 508-292-5728. Donna Miorandi 1 McKean, Thomas From: McKean,Thomas Sent: Thursday,January 24, 2019 4:25 PM To: McLaughlin, Charles Subject: Knights Inn Violations Hi Charlie, Health Inspector Donna Miorandi and I examined the computer records at Knight's Inn Motel this afternoon. We determined there may.be multiple violations of the agreement as follows: - Brown, James—Stayed 80 nights (from October 9, 2018 to January 5, 2019) in a 90 day time period. - Crowson, Jimmy—Stayed 31 consecutive nights from September 2, 2018 through October 10, 2018. - Nicho, Nicolas, Nick, Chuck Nicolas, - Multiple entries of these names without any identification records (no picture ID, no address) This person stayed in the same Room #132 multiple dates from September 17, 2018 January 4, 2019. He stayed at the Motel a total of 34 nights. NOTE: The current temporary manager on duty is not violating the agreement. She is taking ID's of each guests and is limiting the number of nights each can stay. The above violations occurred prior to her employment at this Motel. � . 1 McKean, Thomas I From: McKean,Thomas Sent: Thursday, January 24, 2019 4:25 PM To: McLaughlin, Charles Subject: Knights Inn Violations Hi Charlie, Health Inspector Donna Miorandi and I examined the computer records at Knight's Inn Motel this afternoon. We determined there may be multiple violations of the agreement as follows: - Brown, James — Stayed 80 nights (from October 9, 2018 to January 5, 2019) in a 90 day time period. - Crowson, Jimmy—Stayed 31 consecutive nights from September 2, 2018 through October 10, 2018. - Nicho, Nicolas, Nick, Chuck Nicolas, - Multiple entries of these names without any identification records (no picture ID, no address) This person stayed in the same Room #132 multiple dates from September 17, 2018 January 4, 2019. He stayed at the Motel a total of 34 nights. NOTE: The current temporary manager on duty is not violating the agreement. She is taking ID's of each guests and is limiting the number of nights each can stay. The above violations occurred prior to her employment at this Motel. McKean, Thomas From: McKean, Thomas Sent: Thursday,January 24, 2019 4:25 PM To: McLaughlin, Charles Subject: Knights Inn Violations Hi Charlie, Health Inspector Donna Miorandi and I examined the computer records at Knight's Inn Motel this afternoon. We determined there may be multiple violations of the agreement as follows: - Brown, James—Stayed 80 nights (from October 9, 2018 to January 5, 2019) in a 90 day time period. - Crowson, Jimmy—Stayed 31 consecutive nights from September 2, 2018 through October 10, 2018. - Nicho, Nicolas, Nick, Chuck Nicolas, - Multiple entries of these names without any identification records (no picture ID, no address) This person stayed in the same Room #132 multiple dates from September 17, 2018 January 4, 2019. He stayed at the Motel a total of 34 nights. NOTE: The current temporary manager on duty is not violating the agreement. She is taking ID's of each guests and is limiting the number of nights each can stay. The above violations occurred prior to her employment at this Motel. i Miorandi, Donna Subject: Meeting with Asst.Town Attorney Charles McLaughlin- Knight's Inn Motel Location: Room -'200 Main Training Room Start: Wed 2/13/2019 10:00 AM End: Wed 2/13/2019 11:00 AM, Show Time As: Tentative Recurrence: (none) Meeting Status: Not yet responded Organizer: McKean, Thomas Required Attendees: Miorandi, Donna;Anderson, Robin; Gallant, Therese; Room - 200 Main Training Room _4V a� *10 OV/ G A F �r C c%MA �i 0 ./. '' o • �� ':. ,� .. . . � .. - ,. �, _ " � � � � - - y . . ._, � ` .. r ., -��,, ,r i c ,, � " I Miorandi, Donna From: Miorandi, Donna Sent: Friday, February 1, 2019 8:35 AM To: 'Dave Paananen' Subject: RE: 8 Shootflying Hill Road Thanks Dave! We have had none of them reported. Donna From: Dave Paananen [ma i Ito:d paa na nen @westba rnsta blefi re.com] Sent: Thursday, January 31, 2019 4:47 PM To: Miorandi, Donna Subject: 8.Shootflying Hill Road Hi Donna, The following is a list of times we responded to medical calls at the motel after the agreement. You can check and see if they reported any of them. 01/16/2019 overdose no patient, patient left before arrival 12/02/2018 fall assist no transport 10/11/2018 unresponsive refusal 06/01/2018 diabetic canceled by PD 09/01/2017 priority 2 medical transported Thank you, Dave CAUTION:This email originated from outside of the Town of Barnstable! Do not click links;open attachments or reply, unless you recognize the sender's email address and know the content is safe! i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplic Lion for Misposal 6pstrin Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.16 S Lioa ��r �G( 2) Owner's Name,Address,and Tel.Nob i A IE,c_ S ✓`�t�oT�y/k` fl�L( Assessor's Map/Parcel 23 S 0?3caZ Installer's Name,Address,and Tel.No. -ewr71-c-Dirt 5' Designer's Name,Add less,and Tel.No Type of Building: Scts roh Dwelling No.of Bedrooms - /�/ r I Lot Size 2400 b-0 i sq.ft. Garbage Grinder( ) Other Type of Building ` ' `o 1� ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) cfl� QZJAP C-2�wen.;F_ bk 6 (�' 9 Date last inspected:d Aa)n l s 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 Board of Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. q s �a' l �� Date Issued No. ' / Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes toe PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS ftplicatlon for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f, Owner's Name,Address,and Tel.No. j Assessor's Map/ParrcelXIA in Installer's Name,Address,and Tel.No. hL C`ti`" - C",i� ,;— Designer's Name,Add ess,and Tel.No. Type of Building. sYs r&h 1� Dwelling No.of Bedrooms Lot Size o 0a c7 sq.ft. Garbage Grinder( ) Other, Type of Building (�1�� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 4 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil t Nature of Repairs or Alterations(Answer when applicable) Date last inspected: :�L €. 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 Board of Health. Signed Date >(,l zo(S Application Approved by Date _ , Application Disapproved by T 1 Date for the following reasons ' Permit No. C>I �. '� Date Issued -------------=------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired O Upgraded( ) Abandoned( )by/).,l�c� i,,, �„( �1�i, , (� at -5 has been constructed in accordance with the provisions of Title 5 and t e for Disposal System Construction Permit No.90�`�—1�3 dated LI Installer �, / ", Designer in V64, 4 #bedrooms f v Approved design flow gpd The issuance of this p it shall not be construed as a guarantee that the system will function as designed. Date / Inspector /� T• Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )System located at �,�,,,�, '( '� A ,l A ��1 1, C.PwnT�C,% L 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:Construction must be completed within three years of the date of this permit. < Date Lj —` -2 Approved`by J 11q No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pphtation for Misposal 6pstem Construftion 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System KIndividual Components Location Address or Lot No. ! 1�,6 p o-r v% � v a�> Owner's Name,Address,and Tel.No.�j 1,'IP ?,ATE j Assessor's Ma /Parcel �`�� � P 23`/ .e G�'iw rntt�V-4 Installer's Name,Address,and Tel. 0*1 '"`" Designer's Name,Address,and Tel.No. l ,, 1B- w s- u,-& L 1 j3 Caw•► t j ki Type of Building:S s-rev►+ ILL I v ' I f� 4 Dwelling No.of Bedrooms Lot Size 2-6 qj c o��sq.ft. Garbage Grinder( ) Other Type of Building mo-T 6 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided IV tT gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)�f ¢ S A yv►1YNc•� ��� X&- L,ek Of 1Y4-n(,- Date last inspected: 2--Ol e( 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 Bo d of Hea t Signed Date Application Approved by f 6 Date — Application Disapproved by Date for the following reasons Permit No. O Date Issued _f �} r No. P Fee THE COMMONWEALTH & MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicatlon for Misposal Epstein Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) []Complete System Individual Components Location Address or Lot No.I'll 4 c� o o-r 5:1 j i a�t 1 Q,�� Owner's Name,Address,and Tel.No.D� ; eATAssessor's Ma /Parcel 9 5".- 41'`t N-rt(rZO Installer's Name,Address,and Tel.No.(/hrr P� a Q 0'i Designer's Name,Address,and Tel.No. nbcrL:P' 13• tau,$- CA,IA4C 1 3 (;pvr„+.e✓c.0 Type of Building: Y(,7p�y» 1f1 Dwelling No.of Bedrooms 1" Lot Size 2-6 04 00 y-7g.ft. Garbage Grinder( ) Other Type of Building (1O No.of Persons Showers( ) Cafeteria( .) Other Fixtures i . Design Flow(min.required) 4' gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) � �n� C,n,,,..:j cw, 7r7G6 (t o!( Date last inspected: Z A Agreement: �t 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 Board of Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ©f ' Date Issued I-( J ---- ---------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by S % ,., at „,2T k has been constructed accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 ;L tted L-1 S 1 Installer �[,®�; (�� - Designer /en /01 #bedrooms Approved design flow and The issuance of this e it shall not be construed as a guarantee that the system will ion designe . Date �(ij i o► Inspector /, G� - - r---------- ---------------------------------- ---------------------------- ------------ ----- No. C9/ ( C1 Fee (_7 / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Vermit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at 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. � c Provided:Construction must be completed within three years of the date of this permit. t q Date ( � � ( Approved by I No. ~. f Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliLation for 30ispo8al 6pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Qfndividual Components Location Address or Lot No. 1®a �1,.1��,�t�-c R-� Owner's Name,Address,and Tel.No--Ii)� Assessor's Map/Parcel Z3k-t1V5--1 104,0wh Installer's.Name,Address,and Tel.No.C-zo- 0—sx- Designer's Name,Address,and Tel.No. A Type of Building: Dwelling No.of Bedrooms '' I Lot Size 200 000� sq.ft. Garbage Grinder( ) Other Type of Building t V wtt-0 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. z Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 C,i�v S u ePIK Date last inspected: V/mar l `?-O VC7 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 Board of Health. 2,0 Si Date `� Application Approved by Date �i Application Disapproved by Date for the following reasons Permit No. �-� — Date Issued No. �6 ..- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered;ncomputer:_� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for ]Disposal *pstrm (Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Qndividual Components Location Address or Lot No. $S�eoTrly�,,�1 r(�f2b Owner's Name,Address,and Tel.No:-✓'1 D VA`r6 Assessor's Map/Parcel Installer's Name,Address,and Tel.No.�t�,L)s:` Designer's Name,Address,and Tel.No. .' 'Type of Building: Dwelling No.of Bedrooms IAI 47 Lot Size Z�oO.o p o sq.ft. Garbage Grinder( ) Other Type of Building ry/—O-ra No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) X" Date last inspected:�1/1/1/lAr,r„In —pip V; 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 Board ]Board of Health. u c� Sim. Date -(L� Application Approved by \ Date '(.�.< Application Disapproved by Date for the following reasons Permit No. O _- ('- Date Issued C / --------------------------------------------------------------------------------------------------------------------------------------- i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired ) Upgraded( ) Abandoned( )by ,.)E 11 �P A`�Xt7 1� 1 u IR !�.t�+�C``►� at ;�,, 11 LA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.a6rl" 2 dated IAA— Installer u� �. Designer #.bedrooms Approved design flow gpd The issuance of this permits all not be construed as a guarantee that the system wil do as designed Date t J G t C4 Inspector c ( ( ( , ��� -- .----- ---------- --------------- ---------- - --------------------- --------------------------- ------------------------------- No _ l � Fee ----� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS . . Bisposar *pstrm Construction permit Permission is hereby granted to Construct( ) Repair( 6�-- Upgrade( ) Abandon( ) System located at $ S (.s v o-``- L � k.l Jl ^1� � 0-An-t QK LAC L' 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:Construction must be completed within three years of the date of this permit.,—, C Date Approved by TOWN OF BARNSTABLE SYSTEM P �{ CC�TIO�i.. S ��tithQ l-�ll RD. SEWAGE# ZbL9 ILLAG ASSESSOR'S MAP&PARCEL Z 3`{ - 05 INSTALLER'S NAME&PHONE NO. Ci+ ?6sW QG7 !Z R,60 4- Z IR �-�} SEPTIC TANK CAPACITY S 6c G LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER P i� PERMIT DATE: y " S - q COMPLIANCE DATE: 4 - Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) l nn Feet FURNISHED BYP[-(,C� 1� n o co �1> ILA _.I N _j O O o-;a o _y S H 4 i f �� ��� �. "�vvJvvJC.L�r- Cr�('(9''/� G�. � d�� 1 + y ' , � �, 1 1 No. ®" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9ipfitation for Misposar 6pstem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System C.ixdividual Components Location Address or Lot No. 15 hotz ,� �GA 1L7 , Owner's Name,Address,and Tel.No. Assessor's Map/Parcel .� 0 / Installer's Name,Address,and Tel.No.60, y 4-2— Designer's Name,Addr s,and Tel.No. Type of Building: S LtST�%1ry, Dwelling No.of Bedrooms Lot Size 2,00 z O+ sq.ft. Garbage Grinder( ) Other Type of Building 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) CAA0.-.,g TX, S op Date last inspected: 7�01 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 Board of Healt Signed Date Application Approved by Date — r Application Disapproved by Date for the following reasons Permit No. O'���. / 0 Date Issued ` 5 -- ------------------------------------- No. f J f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered incomputee PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for !�onBtrUction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ividual Components Location Address-or. No. ►ia. Owner's Name Address and Tel.No. Assessor's Map/Parcel - t & 1A Installer's Name,Address,and Tel.No. .� , Designer's Name,Address,and Tel.No. w a C>LkfL (o. Type of Building: �kSTc.A^ IF Dwelling No.of Bedrooms ( " Lot Size Z(OU O} sq.ft. Garbage Grinder( ) Other Type of Building AA No.of Persons Showers( ) Cafeteria( ) Other Fixtures 05 y- 6 Design Flow(min.required) `► ,gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Board of Health. Signed Date Application Approved by " Date V Application Disapproved by Date for the following reasons ' 3 Permit No. (2 Date Issued L -,i --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS I Certificate of Compliance THIS IS TO CERTIFY,that the O site Sewage Disposal system Constructed( ) Repaired O Upgraded( ) Abandoned( )by O.A� o- 7_�Aj2_ at t__l l has been constructed in accordance with the provisions of Title 5�and the for Disposal System Construction Permit No. �� ` dated InstallerL. ,o. Designer #bedrooms Approved design flo gpd The issuance of this permit shall not be construed as a juarantee that the system wil €a ction designed. Date M 114 Inspector � -------------------------------- -------------------- ------- ------------------------------------------------------------- ---------- No. l- - - 4 a-- Fee---C� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repai Upgrade( ) Abandon( ) System located at rx !GL4 „ I-4=1 L j a ( ,ram ,) r" 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:Construction must be completed within three years of the date of this permit. C Date Approved by r/� TOWN OF BARNSTABLE uCATION 16 RD • SEWAGE# 20 H VILLA E ASSESSOR'S MAP&PARCEL 23`t ' O 51 INSTALLER'S NAME&PHONE NO. LWC—,WmE ELM IR36 4 1— gc"Z1 SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER 71r&JDAA PERMIT DATE: L{ — S — 11 COMPLIANCE DATE: '9 9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet' FURNISHED BY CA�P Ec e�1 D E &T D72 N J e� tN N a a r a V 0 N to i 5 aL . a •;�. S S 1 l No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpl tatlon for Disposal *pstem Construction Permit Application for a Permit to Construct( ) RepaiUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S e>(•yam s l (,, Owner's Name,Address,and Tel.No.�! �P (/� 05G Assessor's Map/Parcel3 `� W-.&A?9� �.oIr� Installer's Name,Address,and Tel.No. iLk e. Designer's Name,Address, d Tel.No. �2o�a�•rT ,, �s cam. ?�l Type of Building:5,ongv,, '> I t// Dwelling No.of Bedrooms ^ ,�/, Lot Size sq.ft. Garbage Grinder n ( ) Other Type of Building 1 V lID I No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided N gpd Plan Date Number of sheets Revision Date Title Size.of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) —G� ia> 6 Avu, 1 Date last inspected: Z L 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 of Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �d 0 _ Date Issued L4 s f / No. 1 I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftphration for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) RepaiUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. -� L f Owner's Name,Address,and Tel.No.�� Assessor's Map/Parcel �Qt r,�, , T- G a 0C-v i` Insta�lller's Name,Address,and Tel.Noq�L ,LA-¢ G_�"-C�z, Designer's Name,Address,arld Tel.No Type of Building:!�St" 1 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ., _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) } Date last inspected: N1 I I 4 ---n l 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 Board of Health. Signed Date �'� ' �( � ( , Application Approved by Date r Application Disapproved by Date for the following reasons - Permit No. 19-1 Date Issued ------------ -------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Urtifirate of Compfianre THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at has been constructed in accordance G with the provisions of Title 5 and the f r Dispo I System Construction Permit No. 0!°► " dated Installer Co. Designer . #bedrooms Approved design ow gpd The issuance of this permit shall not be construed as a guarantee that the system will ffunction designed. Date 14 I r Inspector ( �� . . No. O f ! 12 Fee THE COMMONWEALTH OF MASSACHUSETTS r f PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repa0Q_ _ Upgrade( ) Abandon( ) t System located at ' -cf IJ 1 t' � ( g 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:Construction must be completed within three years of the date of this permit. "" Ll C,�� Date L� l Approved by e o�sK� Town of`Barnstable Barnstable ti Inspectional Services BAFiNSTASLE, r Public Health Division prf0�"0�a r 200 Main Street,-Hyannis /A,02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 L CERTIFIED MAIL#7015 1730 0001 4987 9637 March 20, 2019 PATEL, JITENDRA B TR 8 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 8 Shootflying Hill Road, Centerville, SYSTEM A was .inspected on 03/12/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Need to install inlet tee. You are ordered to repair or replace the septic system within two (2)years 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 THE BOARD OF HEALTH L cKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V.Inspection Report Letters Mailing\Conditionally Passes Letters\8 Shootflying Hill Road Centerville System A.doc ate`-os9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments :D �t 8 Shootflying Hill Road System A rrQ0 Property Address J Knights Inn : Owner Owner's Name information is Ma 02632 3-12-19ill t enerve required for every C page. City/Town State Zip Code Date of Inspection r1= 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. `���,ttttl/Itf►,,,7� A\A OF IHgS;��ii��i Important:When A. Inspector Information filling out forms on the computer, '� DAMES :R, use only the tab James D.Sears SFAgS 1 key to move your Name of Inspector cursor-do not > '• use the return Capewide Enterprises %ter:•FRTtF�� key. Company Name iNSp� ```o� . 153 Commercial Street Mashpee MA 02649 City/Town State Zip Code redcn 508-477-8877 31623 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 3-14-19 Ind ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 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: i 1 ❑ 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: Conn Pass - inlet tee. The system is a 1000 Gal. Tank and pit. 2 System Conditional) Passes: Y Y ® 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): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 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): Need to install inlet tee. ❑ 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 Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12 -19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) i ❑ 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 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12 -19 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 is less than 6" below invert or available volume is less than '/z day flow p,7— ❑ ® 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 t5insp.doc•rev.712612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts u - Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A V Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12 -19 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �u 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12 -19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: , Number of current residents: 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 ❑ 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: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Motel j Design flow(based on 310 CMR 15.203): 660 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 6- 1 Bed Rm Motel Room s 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: NA Date Other(describe below): 3. Pumping Records: Source of information: NA 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts = r Title 5 Official Inspection Form '^ {Ii� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l51` j 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12 -19 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 4. Type of System: ® Septic tank, 11111 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: NA Were sewage odors detected when arriving at the site? ❑ Yes Z No. 5. Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: it feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness off - Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 1' below grade w/both covers at grade. Three inlet's,Two w/tee's one no tee. Outlet tee. Need to install inlet tee. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form <F' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 page. City/Town 7State 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 I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 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: 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 No Box 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name I information is Centerville Ma 02632 3-12-19 required for every 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: 1 ❑ leaching chambers number: ❑ 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 I Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v% 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 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.): Leaching is a 1000 Gal. Precast Pit. Pit and cover at 21" below grade. Pit dry w/stain line at 30". No sign of over loading. 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is Centerville Ma 02632 3-12 -19 required for every 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r A 8 Shootflying Hill Rd Craigville Motel (Left side Rooms#22432) _...... Property Address Owner Owner's Name information is Centerville MA 02632 required for every State Zip Code Date of Inspection page City/Town — D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Localo where public water supply enters the building. Check one of the boxes below: ® hand-sketch'in the area below ❑ drawing attached separately -__. P J-�P n A It Y3' A 10 A•3: 43' /3-3 ' 3 M `- qo � z o S ysrrm 8 t5ins•3M3 Tille 6 Official Inspection Form:Subsurface Sewage Disposal System•Palle 1:," Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na 20'+ Estimated depth to{ ground water: 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: 6-2-99 Date ❑ Obsetved site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. rear newer system. T.H. on Design plan 6-2-99 14 no G.W.. Rear T.H. area 20' lower then system. 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 r ; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System A Property Address Knights Inn Owner Owner's Name information is required for every Centerville Ma 02632 3-12-19 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 t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Addresst Knights Inn Owner Owner's Name -� information is _ required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection U7 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. 0F .MgS Important: forms When A. Inspector Information S•►� fillip out f �o; '• G on the computer, =�: JA M ES use only the tab James D.Sears =o key to move your Name of Inspector cursor-do not Capewide Enterprises r'•.�' a` use the return ''i�! .FRTtF�`` •RO Company pany Name i��FG 5 I N Sp�G,,\` 153 Commercial Street � "ITV Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 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 apm��, 3-14-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank and pit. 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): t5insp.doc•rev.7/26/2018 Title 5 Official tnspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form Not for Voluntary Assessments L 8 Shootflying Hill Road (System B) u Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 is less than 6" below invert or available volume is less than '/z day flow Pi 7— i ❑ ® 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 11 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 ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form <le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 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 ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form `i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Motel Design flow(based on 310 CMR 15.203): 550 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 5-1 Bed Rm Motel Rooms 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: NA Date Other(describe below): 3. Pumping Records: Source of information: NA 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form ^? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, VNIRRISHEM 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: NA 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): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 9 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form f.a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 14" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) r� If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Oil Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" Mow were dimensions determined? Asbuilt-TapeSludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 14" below grade w/both covers at grade. In and out tee. t5insp.doc•rev.7/26/2018 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 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 tl'o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: 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 No Box 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V� 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: 1 ❑ leaching chambers number: ❑ 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 Title 5 Official Inspection Form `li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.): Leaching is a 1000 Gal. Precast pit. Pit and cover at 21" below grade. Pit dry w/stain line at 3'. No sign of over loading. 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 Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootfl in Hill Road (System B Y 9 � Y ) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hili Rd Craigville Motel (Left side Rooms#22-#32) _..._.. Property Address Owner Owner's Name information is Centerville MA 02632 required for every State Zip Code Date of Inspection page. Citfrown D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties Ili 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 c I �O K ®P r—S5 -r A •�. R A-3_ J4�' 13.3= -1/o -G (��3 S ysrcm •j N60-`F4U/10C- Tue 5 officiai Inspection Forth.Subsurface sewage Disposal system•Pai ie 1E,d ' t5ins•3f13 Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No , Estimated depth torfhigh ground water: 20'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: 6-2-99 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: T.H. on Design plan 6-2-99 14' no G.W.. Bottom of pit at 8' below grade. T.H. Rear newer system. Rear T.H. area 20' Lower then system. 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 u 8 Shootflying Hill Road (System B) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 pFTHE Tp� Town of Barnstable Barnstable P` ~ Inspectional SeServicesA�-America City 1BAftNf3TABL FE q Public Health Division pry° �s 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9637 March 20, 2019 PATEL, JITENDRA B TR 8 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 8 Shootflying Hill Road, Centerville, SYSTEM C was inspected on 03/12/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Need to replace outlet line. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the-deadline period will result in future enforcement action. t PER ORDER OF THE BOARD OF HEALTH oma Qe Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\8 Shootflying Hill Road Centerville System C.doe Commonwealth of Massachusetts 0?311- D59 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� 8 Shootflying Hill Road (System C) Property Address i*1 Knights Inn Owner r Owner's Name � information is ACenterVllle MA 02632 3-12-19reguired for every page. City/Town State Zip Code Date of Inspection,,, Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. `\`\pau11oF►fq�����o i Important:When A. Inspector Information 6'( �4°filling out forms , I�(Q �., :py,� on the computer, O? G use only the tab James D.Sears __'�. JAMES key to move your Name of Inspector Go cursor-do not Capewide Enterprises use the return — % A L) O key. Company Name �� ��: i �'r�T I TF . 153 Commercial Street ''��iiiF 5 IN SpEG11 0" Company Address Mashpee MA 02649 City/Town State Zip Code reUan 508-477-8877 S1623 elephone 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 3-14-19 I ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 �lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /'- ;�� 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owners Name information is required for every Centerville MA 02632 3-12-19 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: ❑ 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: Conn pass- line repair. The system is a 3500 Gal. Tank. 2000 Gal. per plan ,two D Box's and 12 chamber's. 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): t5insp.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 la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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): Need to repair outletl ❑ 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,V 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �' to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 MEMI is less than 6" below invert or available volume is less than '/z day flow 4SAcIIIM6 ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts I`p Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootfl ing Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .V 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 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 ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Motel Design flow(based on 310 CMR 15.203)'. 1540 Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): 14 Bed RM's Motel Room s 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: NA Date Other(describe below): 3. Pumping Records: Source of information: NA 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Lila Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name requinform r on is Centerville MA 02632 3-12-19 requiredd for every 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: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 26" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts j�p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System C) 'u Property Address. Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: Tank 1 T 18"2 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: Tank 1 Tank-2 3500 2000 Gal. H-20 Sludge depth: NA" 0" Distance from top of sludge to bottom of outlet tee or baffle NA" 28" Scum thickness ill Oil Distance from top of scum to top of outlet tee or baffle NA" 11" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? .Sludge Ju Tape Sludge udge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank#1 at working level w/Tinlet tee. Tank at 16" Below grade w/inlet cover steel at grade and outlet cover under black top .Tank#2 at 18 " below grade w/Both cover's at grade in and outlet tee's. Note inlet tee under water. Need to lower outlet tee. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .11; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name requinform r on is Centerville MA 02632 3-12-19 requiredd 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: 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box's are clean and solid w/cover's at grade. No sign of over loading or solid carry over. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form <ia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information isequired or every Centerville MA 02632 3-12-19 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: 12 ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.): Leaching is (12) 500 Gal. dry well chamber's w/4'stone. Chamber's are dry,clean like new. Two cover's at grade. 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is Centerville MA 02632 3-12-19 required for every _ 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 i c Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;V 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Q i 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 _ W Property Address Owner Owner's game Information is Centerville MA 02632 reqquireduired for every page. Cityrrown State Zip Code Date of Jnspecbon D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including 1 im, at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Local:- where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below [{ drawing attached separately Lk Acts ors A-I cza- ''rc40 5 �s�� — � o So >d I � Room6't 2 -'2I I _tot :C'd xc 1-9 o t5ins•31`13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Ptr t, .5 of 17 I Commonwealth of Massachusetts ,A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 8 Shootfl in Hill Road (System C Y 9 ( Y ) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells JV0 Estimated depth to high ground water: 14' 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: 6-2-99 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health- explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H.on Design plan 6-2-99 14' no G.W. ,. 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 I.? Title 5 Official Inspection Form jot Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System C) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable Barnstable SHE T� . ;erica C-i Inspectional Services BARNbTABM KAM Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9637 March 20, 2019 PATEL, JITENDRA B TR 8 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 8 Shootflying Hill Road, Centerville, SYSTEM D-1 was inspected on 03/12/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Need to replace outlet line. You are ordered to repair or replace the septic system within two (2)years 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 THE BOARD OF HEALTH 'i�t cKean, R. ., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\8 Shootflying Hill Road Centerville System D- Ldoc r �3y- ash Commonwealth of Massachusetts ,�,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inns Owner Owners Name information is required for every Centerville MA 02632 3-12-19 : 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. ` 01111.1�F pUiii,/zi Important:When filling out forms A. Inspector Information �� �g�y� �•`o�� , 9�y,, on the computer, G use only the tab James D.Sears f�:: JAM ES m? key to move your Name of Inspector cursor-do not Ca ewide Enterprises =*' '* key y the return Compan Name �� P'°��; y � ' •... ••'' � N� 153 Commercial Street I N sIE�'�xo``N Company Address ',���� Mashpee MA 02649 City/Town State Zip Code B>m 508-477-8877 S 1623 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 3-14-19 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 I Commonwealth of Massachusetts (P Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 8 Shoofflying Hill Road (System D-1 Property Address Knights Inn Owner Owners Name information is re uired for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection h 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: Conn Pass Tank-outlet line Broken. Note: Outlet line dumping out on to ground. The system is a 1500 Gal. Tank and two pits. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts I` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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): Need to replace line tank to pit. ❑ 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.7/2612018 Tide 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 8 Shootfl in Hill Road (System D-1 Y 9 ( Y ) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 dKM1=is less than 6" below invert or available volume is less than '/z day flow P0- 1:1 ® 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 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootfl in Hill S Y 9 Road (System D-1) Property Address Knights Inn Owner Owners Name information is required for every Centerville MA 02632 3-12-19 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 f Commonwealth of Massachusetts s. Title 5 Official Inspection Form �R lw Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 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 ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) u- Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Motel Design flow(based on 310 CM NAR 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: NA Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for um in : P p 9 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V _8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is Centerville re wired for every MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ❑ 40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH - 20. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 20"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: 1500 Gal. Precast H-20 Sludge depth: 2° Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-TapeSludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 20" below grade w/both covers steel at grade. In and outlet tee's. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Traplocate on site plan): ( p I� 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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �L 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is ill t enerve MA 02632 3-12-19 required for every C � City/Town/Town � page. Y State Zip Code p g p 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 No Box 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: 2 ❑ leaching chambers number: ❑ 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form ^li; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.): Leaching is two 1000 Gal. precast pit's. Both pits dry w/no sign of over loading. 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 Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r— t. Commonwealth of Massachusetts ., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . � a 8 Shootflying Hill Rd Craigville Motel (Roams 12-21, 33-42) MAP-234 PARGEL-059 Property Address Owner Owner's game Information Is required for every Centerville MA 02632 _..,... page. Cfty/Tewn State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:f1mvide a view of the sewage tiisposai system,including Iier at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Lctcco, where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below [3 thawing attached separately LIi;A�H �r A-If� JAPt- S `�5��� -. ` @0 Y5771 In 1s�/j" o � O 1 Fr M I Roa/if-w! 2 -;021 ! t6lne•3113 Title 5 Official Inspection Farm:Subsurtace Sewage Disposal System•Pit n .5017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells JVD 14' Estimated depth tcs►high ground water: 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: 6-2-99 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. 6 -2 -99 on design plan 14' no G.W.. T.H.rear newer system. Bottom of pit at 9'-6" below grade. 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 c ssachusetts Commonwealth of Ma �n Title 5 Official Inspection Form .N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road (System D-1) V Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable Barnstable AN-Amea City Inspectional Services v BARrrblASM H" Public Health Division i639. `� m ArFe AAA" 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9637 March 20, 2019 PATEL, JITENDRA B TR 8 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 8 Shootflying Hill Road, Centerville, SYSTEM D-2 was inspected on 03/12/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Need to replace the block cesspool with H2O septic tank and replace the outlet line. You are ordered to repair or replace the septic system within two (2)years 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 TH BOARD OF HEALTH Thoma's NtcKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\8 Shootflying Hill Road Centerville System D- 2.doc Commonwealth of Massachusetts pi Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r w 8 Shootflying Hill Road ( System D-2) L Property Address ,< Knights Inn r�ro Owner Owners Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection u, Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information s9cy filling out forms •'� •�' on the computer, �� JAM �'' use only the tab James D.Sears = ;m key to move your Name of Inspector —a cursor-do not CEnterprises use the return a ewide key. h 153 Commercial Street ''��F S•�N SPE`'� V� Company Address Mashpee MA 02649 City/Town State Zip Code re+�n 508-477-8877 S1623 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 3-14-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 I� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: ❑ 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: Conn pass -need to replace block pool w/H-20 Tank and outlet line. The system is a old block c pool not H-20 in black top drive way. 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): t5insp.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 Foram Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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): Need to replace old block c pool w/H-20 Tank ' need to replace old outlet line ❑ 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 Title 5 Official Inspection Form <> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) u Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 wiithin 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 U 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 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 <24 Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owners Name information is required for every Centerville MA 02632 3-12-19 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)] I 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 F!, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 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 ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 8 Shootflying Hill Road ( System D-2) , Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Motel Design flow(based on 310 CMR 15.203): NA 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: NA Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form , - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tl� 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® 1119111MMIXEM soil absorption system ® IN=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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 30" Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Orange Burge t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: No Tank 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: 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 o,'18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) v� Property Address Knights Inn Owner Owner's Name Information is Centerville MA 02632 3-12-19 required for every page. City/Town 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cent.) 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 No Box 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.): t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owners Name information is required for every Centerville MA 02632 3-12-19 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: Outlet line old blocked orange burge pipeing. Belive line go's to system D-1 two pits. Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) u Property Address Knights Inn I Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.): NA 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert dry Depth of solids layer dry Depth of scum layer dry 6' Dimensions of cesspool Materials of construction old block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Old blockC Pool Not H-20 in drive way. Need to replace w/ H-20 Tank. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 8 Shootflying Hill Road ( System D-2) v Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 ' Commonwealth of Massachusetts &MTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1a 8 ShootFlying Hill Rd Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Owner Owner's game Information is Centerville MA 02632 _ required for every Clty/Town state Zip Code Date of Jnspecuon page. _......_ D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including Bess: at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Local.,: where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below {� -drawing attached separately ......... E'FA4M S �S ��� _ , C tA T 4 O 8 T_ E i , ' '-F/ I-fy Wine•319 Mile 5 Official Inspection Form:Subsurface Sewage Disposal System•I'rt n .5017 Commonwealth of Massachusetts Title 5 Official Inspection Form pia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �d Estimated depth tcf high ground water: 2 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: 6-2-99 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 6-2-99 -14' No G.W.. T.H. rear newer system. Rear T.H. area 20' lower then system. 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 1 Commonwealth of Massachusetts Title 5 Official Inspection Form /.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road ( System D-2) Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 any-a�q Commonwealth of Massachusetts Title 5 Official -inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,V 8 Shootflying Hill Road System E Property Address i*RI Knights Inns i Owner Owner's Name 'w information is required for every Centerville MA 02632 3-12-19 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. L ```,o0i OFrrUiiiZ���i fiIWA lling out formsen Ins G6 9 ortant:Wh A. Inspector Information !:# (�(� on the computer, James D.Sears �� JAMES m= use only the tab key to move your Name of Inspector cursor-do not �� '_ Capewide Enterprises use the return �• l r � Company Name key. 153 Commercial Street ,��� �FrSiiNSP`E;'���`��\` "1� V Company Address Mashpee MA 02649 City/Town State Zip Code ieuon 508-477-8877 S 1623 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 / 3-14-19 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5i1sp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,'P Title 5 Official Inspection Form tia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: The system is a 1000 Gal.Tank and pit. 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): t5insp.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 Ylo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is Centerville MA 02632 3-12-19 required for every 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owners Name information is required for every Centerville MA 02632 3-12-19 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.7/26/2018 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 e 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 9111111111M is less than 6" below invert or available volume is less than '/2 day flow PiIr- ❑ ® 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 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 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is Centerville MA 02632 3-12-19 required for every 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 in; was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with El ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 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 ❑ 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: Date t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Motel Design flow(based on 310 CMR 15.203): 550 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 5- 1 Bed RM Motel Room's 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: NA Date Other(describe below): 3. Pumping Records: Source of information: NA 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank,1111131MBEIRU 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4' PVC SCH -40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owners Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 25"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene - ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 25" below grade w/inlet cover at grade and outlet cover at 6". Three inlet's w/outlet baffle. No sign of leakage or over loading t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 �u 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is Centerville MA 02632 3-12-19 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: 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 No Box 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: 1 ® leaching chambers number: ❑ 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 Title 5 Official Inspection Form R -1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System E `J Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. Cityfrown 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.): Leaching is a 1000 Gal. Precast Pit. Pit and cover at 22" below grade. Pit dry w/stain line at 2'w/no sign of over loading. 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form aI e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is Centerville MA 02632 3-12-19 required for every 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 i • Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflyina Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I • Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 ShootFlying Hill Rd Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 _ Property Address er ownefs.N=e ` ',nfurmation is Centerville _ MA 02632 _.. required for every State Zip Code Date of inspection page, City/Town --• D. System Information (cont.) Sketch of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ ,drawing ached separately I 1 s �srM A � t . a� O A - : 4r,•-qv 3Q` --- s - �- 412' a-- r- - °77 ' qg 3 - qJ Title 5 Official inspection form:Subsurface Sewage Disposal system•Page 15 c i'7 t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form M1,e� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments LV 8 Shootflying Hill Road System E Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 t high ground water: 14' 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: 6-2-99 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Bottom of pit at 8' below grade. T.H. on design plan 6-2-99 14' no G.W.. T.W.Rear Newer system. Rear T.H. area 20' lower then system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2612018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Fie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System E �u Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ��°Frtt�rays Town of Barnstable Barnstable Oftwica City Inspectional Services �A i639. Public Health Division ° + 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9637 March 20, 2019 PATEL, JITENDRA B TR 8 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 8 Shootflying Hill Road, Centerville, SYSTEM F was inspected on 03/12/2019 by James D. Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Need to replace three (3) main lines and the line to the septic tank. You are ordered to repair or replace the septic system within two (2) years 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 TH BOARD OF HEALTH omas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\8 Shootflying Hill Road Centerville System F.doc I , Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F r+ Property Address Knights Inn Owner Owner's Name a::• information on is Centerville MA 02632 3-12-19 a required for every �-- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. O` N OF Important:When A. Inspector Information c filling out forms p 67 13le u�0 e� y on the computer, = �' G p James D.Sears _�; JAMES rN,, use only the tab — -�— key to move your Name of Inspector C r,0 ;y cursor-do not Capewide Enterppises use the return ��� key. Company Name �i, (. •... . 153 Commercial Street 4i�j�q�5/INS? ,�``����� ICI Company Address Mashpee i MA 02649 City/Town State Zip Code 508-477-8877 S1623 _ 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 ins'pectiQn I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3-14-19 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: ❑ 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: Conn pass- replace four lines. Replace block pool w/tank. The system is a block pool to 1000 Gal. Tank and pit. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts i? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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): Need to replace four lines see pg 16. Need to replace block pool w/tank ❑ 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 Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �u 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form I' Fla Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is Centerville MA 02632 3-12-19 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 1111MM is less than 6" below invert or available volume is less than '/2 day flow A7— ❑ ® 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 t5insp.doc•rev.7126/2018 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 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 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 ❑ 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: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Motel Design flow(based on 310 CM 15.203): 660Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): 6-1 Bed Room Motel Room's 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: NA Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 600 Gal's gallons How was quantity pumped determined? Gage on Pump Truck Reason for pumping: Part of Inspection t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron ❑ 40 PVC ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is old orange burge. Need to replace three main lines and line into tank. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 l f Commonwealth of Massachusetts IF Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 28"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal.Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level w/both covers at grade. In and outlet tee's. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018 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 �V 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 111 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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: 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 No Box 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 118 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V, 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: * p g 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: w Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form ale Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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.): Leaching is a 1000 Gal. pit w/cover at 10" V water in pit. No sign of over loading. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert 3" Depth of solids layer 6" Depth of scum layer 3" Dimensions of cesspool 6' 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.): Main C Pool old block w/three lines in no inlet tees one out w/broken sweep. Pipeing in and out of pool old orange burge. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Shootflying Hill Road System F �V Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 c Commonwealth of Massachusetts x ip Title 5 Official Inspection Form Fia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V� 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 page. City/Town 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 w Commonwealth.of, -Wa chusetts Title 5 Offid'Ali Inspection Form } o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments allz� ,. . , 8 Shootflying-Hill-Rd—•Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 _ - Property Address_ er - -- ' '�nfortnation is Ownersl�ame MA 02632 required for every Centerville 'Page. City/Town. State Zip Code Date of Inspection D., System Information (cont.) Sketch Of Sewage Disposal System: Provide a.viev.,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 i S YSrM .. j ® R — D : 41 ..�� v✓ �, coa��R tea '� � � P,+AK11Z I a-3 A 3 "c 3� � Q - � ` 3 �' G�- ` 1 v I a-g•q w Q = y1 [77 Title 5 offidel Inspection Forth:Subsurface Sewage Disposal System•Page 15 c f'7 t5ins•3113 Y Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is required for every Centerville MA 02632 3-12-19 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 t hi�ground water: 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: 6-2-99 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Bottom of pit at 7' below grade. T.H. on design plan 6-2-99 14' no G.W.. T.H.rear newer system. Rear T.H. area 20' lower then system. 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 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Shootflying Hill Road System F Property Address Knights Inn Owner Owner's Name information is Centerville MA 02632 3-12-19 required for every 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 Z. 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.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s. 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector. I / key to move your cursor-do not Dion C. Dugan "` h use the return Name of Inspector j key. Dugan Construction my Company Name 1543 Main St. Company Address Brewster MA 02631 Cityfrown State Zip Code 508-237-3461 SI#60 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and thafthe 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'rnaintenance`of on�site sewage disposal systems. I am a DEP approved system inspector pursuant46 Section j;5.340rof Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails r3 � rya ❑ Needs Further Evaluation by the Local Approving Authority M Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. L'LT dI �gi �I t5ins-3/13 Title 5 Official Inspection Forth.Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,,D or E t always complete all of Section D A) 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber_.pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins-3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M s 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Flame information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last'year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. n ion of cesspool or privy is within 100 feet of a surface water su I or A portion PP Y Y P P P vY ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection El El Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official inspection Forrw.Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes S No 1 gat I�®�G � Water meter readings, if available(last 2 years usage(gpd)): 2012011 gal . 4 0 76a 000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: MOTEL Design flow(based on 310 CMR 15.203): 1210 gpdGallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): 11 - 1 bdrm hotel rooms Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins-3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 60%currently occupied Date Other(describe below): General Information Pumping Records: Source of information: see attached Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v1M , 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner owner's Name information is Centerville MA 02632 8/26/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: installed: unknown, no records on file at B_C.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >50'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints are tight; venting at roof; no signs of leakage Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) two tanks:#1 1,000 gal_ #2 converted cesspool w/outlet sweep to 1,000 gal septic tank If tank is metal, list age: years Is age confirmed b a Certificate of Compliance? attach a co of certificate ❑ Yes ® No 9 Y P ( PY ) Dimensions: see above note 2" Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1 Tank and tees are in good condition;no signs of leakage; Recommend maintenance pumping every 3 yrs. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15is.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4 i 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.): system#1 and#2: no D-Box found at time of inspection. (none) Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: two 6'x 6'w./4'stone 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit#1 found w/40" of liquid in it; Pit#2 found w/36"of liquid in it; no signs of failure. 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 I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owners Name information is Centerville MA 02632 8/26/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A " e o iYi e A - 0 _ 41 _ R ' C r - '77 A ( — © C I 22 A - i : 31 EA ,3c� G A W t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: By perk test on 06/02/99; for upgrade of system out back, behind motel. 12' deep no groundwater encountered; >20'separation. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Shootflying Hill Rd Craigville Motel (Right side Rooms#1411) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked • Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i I t5ins-3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 17 of 17 BYSTREET 22-Sep-14 Hsi# Street Village Prop Owner Date Hauler Source 0 Shootflying Hill Rd Bamstable Cape Cod Tourist Info 2/8/2001 Macomber Cesspool 349 Shootflying Hill Rd Barnstable Winsor,David 3/l/2000 Ellis Septic 498. Shootflying Hill Rd Barnstable Klun 10/24/2005 A&B Canco Septic 386 Shootflying Hill Rd c Gleyzer 12/7/2011 Wind River Septic 453 Shootflying Hill Rd c MacDonald 9/16/2008 LeBoeuf Septic Cesspool 786 Shootflying Hill Rd c Locke 1/11/2012 Capewide Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel . 9/4/1998 Macomber Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel 8/27/1999 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel 8/27/1999 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel 9/7/1999 Bortolotti Septic 0 Shootflying Hill Rd Centerville Lake Wequaquett TOB 12/11/2002 A&B Canco Cesspool 0 Shootflying Hill Rd Centerville _ Macomber 2/23/2004 . Macomber Septic 0' Shootflying Hill Rd Centerville Lake Wequaguet 9/29/2005 A&B Canco Septic 0 Shootflying.Hill Rd Centerville Lake Wequaquet 10/23/2007 Blue Water Tight Tan 0 Shootflying Hill Rd Centerville Wequaquet Lake 10/4/2010 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Motel 11/5/2010 Gibbs Septic 0 Shootflying Hill Rd Centerville Craigville Motel 11/5/2010 Gibbs Septic 0 Shootflying Hill Rd Centerville Craigville Motel 11/5/2010 Gibbs Septic 0 Shootflying Hill Rd Centerville Wequaquet Beach 11/22/2011 Bortolotti Septic 0 Shootflying Hill Rd Centerville Wequaquot Lake 11/2/2012 Bortolotti Septic 0 Shootflying Hill Rd Centerville Weququet Lake Beach 10/22/2013 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Motel 4/17/2014 Gibbs Septic 0 Shootflying Hill Rd Centerville Craigville Motel 4/17/2014 Gibbs Septic 1 Hse# Street Village Prop Owner Date Hauler Source 8 Shootflying Hill Rd Centerville Craigville Beach Motel 4/27/1999 Sep tech Cesspool 8 Shootflying Hill Rd Centerville Craigville Motel 10/30/2000 Sep tech Septic 8 Shootflying Hill Rd Centerville Craigville Motel 10/30/2000 Sep tech Septic 8 . Shootflying Hill Rd Centerville Craigville Motel 10/30/2000 Sep tech Septic 8 Shootflying Hill Rd Centerville Craigville Motel 12/1/2003 Ellis Septic 8 Shootflying Hill Rd Centerville Craigville Motel 12/1/2003 Ellis Septic 8 Shootflying Hill Rd Centerville Craigville Motel 12/1/2003 Ellis Septic 8 Shootflying Hill Rd Centerville Craigville Motel 11/2/2005 Ready Rooter Septic 8 Shootflying Hill Rd Centerville Craigville Motel 11/2/2005 Ready Rooter Septic 8 Shootflying Hill Rd Centerville Craigville Motel 11/2/2005 Ready Rooter Septic 8 Shootflying Hill Rd Centerville Craigville Motel 4/3/2012 Gibbs Septic 8 Shootflying Hill Rd Centerville Craigville Motel 4/3/2012 Gibbs Septic 8 Shootflying Hill Rd Centerville Craigville Motel 5/28/2014 DeBarros Septic Septic 68 , Shootflying Hill Rd Centerville Coelho 7/26/2011 DeBarros Septic Septic 68. Shootflying Hill Rd Centerville Coelho,Marcio 6/20/2012 DeBarros Septic Septic 82. Shootflying Hill Rd Centerville Trought 5/21/2014 JM Barros Septic 109 Shootflying Hill Rd Centerville Childs 3/19/2007 Macomber Septic 115 Shootflying Hill Rd Centerville Macomber 9/8/1999 Macomber Septic 145 Shootflying Hill Rd Centerville Roberts 6/4/2014 JM Barros Septic 157 Shootflying Hill Rd Centerville McLaughlin 12/6/2000 A&B Canco' Septic 157 Shootflying Hill Rd Centerville Averinos 1/5/2004 Bortolotti Septic 157 Shootflying Hill Rd Centerville Averinos 4/29/200$ Bortolotti Septic 157 Shootflying Hill Rd Centerville Averinos 9/2/2010 Bortolotti Septic 157 Shootflying Hill Rd Centerville Averinos 6/16/2014 Bortolotti Septic 169 Shootflying Hill Rd Centerville Fernandes 7/5/2000 Macomber Septic 169 Shootflying Hill Rd Centerville Fernandes 10/17/2006 Macomber Septic 2 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every Page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �Q on the computer, I U use only the tab 1. Inspector key to move your cursor-do not Dion C. Dugan use the return Name of Inspector key. Dugan Construction �1 Company Name 1543 Main St. Company Address Brewster MA 02631 • Cityrrown State Zip Code 508-237-3461 SI#60 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. TM inspection was performed based on my training and experience in the proper function and fijaintenanc4e�of onte sewage disposal systems. I am a DEP approved system inspector pursuant�to Section 1 .340 Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails y ❑ Needs Further Evaluation by the Local Approving Authority a c�_ Inspector's Signature Date - , The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 65 •3113 Tide 5 Offici2l Form:S,�h.Aara Sewage Dispasa System•Page 1 d 17 -\ Commonwealth of Nlassachuseits_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 3342) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3113 Title 5 Of ial Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Offic-ial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's flame information is Centerville MA 02632 8/26/14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND{Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Furtlw Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonvvealtli of IVlassachusetts- Title 5 Official Inspection Form mSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 ,p-- Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. 0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15_303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system_considered.a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM s 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Z ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): gpd t5ins•3113 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 per. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 6��°� Water meter readings, if available(last 2 years usage(gpd)): 2011 gal 1,0 2012 gal t t 7OCR Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: MOTEL Design flow(based on 310 CMR 15.203): 2,530 gpdGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 23 bdrms(20- 1 bdrm hotel rooms+ 3 bdrm.suite) Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 60%currently occupied Date Other(describe below): One 3,500 gal.septic tank and another 2,000 gal.septic tank; w/3 D-Boxes ; 2 6'x 6'leach pits w/4'stone and two leach fields each w/S 500 gal.leach chambers w/4'stone. General Information Pumping Records: Source of information: see attached Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the 11A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-g p y Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: installed: estimated 10/1999 from plan on file B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): >50' Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints are tight; venting at roof; no signs of leakage Septic Tank(locate on site plan): ' Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain) two tanks:#1 3,500 gal. #2 2,000 pal.; cast iron covers built up to grade. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: see above note Sludge depth: 2" &3" t5ins-W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" &27' Scum thickness 1" &2" Distance from top of scum to top of outlet tee or baffle 4" & 4" Distance from bottom of scum to bottom of outlet tee or baffle 13" & 12" How were dimensions determined? by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and tees are in good condition;no signs of leakage; Recommend maintenance pumping every 3 yrs. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Tide 5 Official tnspecdon Fonn:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of 1l-assachuset#s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): system#1 : 3 D-Boxes found; system#2 0 D-Boxes found-none D-Boxes found in good condition w/some signs of carry over; no sign of leakage. 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.): i *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 3342) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: two 6'x 6'w/4' stone ® leaching chambers number: 12 500 gal. w/4'stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit#1 found w156"of liquid in it;Pit#2 found w/38"of liquid in it;]Each galleries were found w11 of liquid in them at time of inspection; no signs of failure. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 -Corr>Imonwealth of Massachusetts - ---- - - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required"for every Centerville MA 02632 8/26/14 per. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts - - _ Title 5 Official Inspection Form lu — Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owners Name information is required for every Centerville MA 02632 8/26/14 per. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including flies to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below drawing attached separately [a L,�AcN fi 4It+1 c.EAcN r[ ALL 60V DE 0 t2 E__a� ROM'S �33 qZ � I Rwli c' 12 -02I W I � I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust owner Owner's(dame information is required for every Centerville MA 02632 8/26/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface water ® Check cellar Shallow wells Estimated depth to high ground water: >12 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: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: By perk test on 06/02/99; for upgrade of system. 12'deep no groundwater encountered; >12' separation. rBefore filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ,per -\ - - - Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Rooms 12-21, 33-42) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 official inspection form:Subsurface Sewage Disposal System•Page 17 of 17 BYSTREET 22-Sep-14 Hsi# Street village Prop Owner Date Hauler Source 0 Shootflying Hill Rd Barnstable Cape Cod Tourist Info 2/8/2001 Macomber Cesspool 349 Shootflying Hill Rd Barnstable Winsor,David 3/1/2000 Ellis Septic 498 Shootflying Hill Rd Barnstable Klun 10/24/2005 A&B Canco Septic 386 Shootflying Hill Rd c Gleyzer 12/7/2011 Wind River Septic 453 Shootflying Hill Rd c MacDonald 9/16/2008 LeBoeuf Septic Cesspool 786 Shootflying Hill Rd c Locke 1/11/2012 Capewide Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel 9/4/1998 Macomber Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel 8/27/1999 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel 8/27/1999 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Beach Motel 9/7/1999 Bortolotti Septic 0 Shootflying Hill Rd Centerville Lake Wequaquett TOB 12/11/2002 A&B Canco .Cesspool 0 Shootflying Hill Rd Centerville Macomber 2/23/2004 . Macomber Septic 0 Shootflying Hill Rd Centerville Lake Wequaguet 9/29/2005 A&B Canco Septic 0 Shootflying.Hill Rd Centerville Lake Wequaquet 10/23/2007 Blue Water Tight Tan 0 Shootflying Hill Rd Centerville Wequaquet Lake 10/4/2010 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Motel 11/5/2010 Gibbs Septic 0 Shootflying Hill Rd Centerville Craigville Motel 11/5/2010 Gibbs Septic 0 Shootflying Hill Rd Centerville Craigville Motel 11/5/2010 Gibbs Septic 0 Shootflying Hill Rd Centerville Wequaquet Beach 11/22/2011 Bortolotti Septic 0 Shootflying Hill Rd Centerville Wequaquot Lake 11/2/2012 . Bortolotti Septic 0 Shootflying Hill Rd Centerville Weququet Lake Beach 10/22/2013 Bortolotti Septic 0 Shootflying Hill Rd Centerville Craigville Motel 4/17/2014 Gibbs Septic 0 Shootflying Hill Rd Centerville Craigville Motel 4/17/2014 Gibbs Septic 1 Hse# Street Village Prop Owner Date Hauler Source 8 Shootflying Hill Rd Centerville Craigville Beach Motel 4/27/1999 Sep tech Cesspool 8 Shootflying Hill Rd Centerville Craigville Motel 10/30/2000 Sep tech Septic 8 Shootflying Hill Rd Centerville Craigville Motel 10/30/2000 Sep tech Septic 8 . Shootflying Hill Rd Centerville Craigville Motel 10/30/2000 Sep tech Septic 8 Shootflying Hill Rd Centerville Craigville Motel 12/1/2003 Ellis Septic 8 Shootflying Hill Rd Centerville Craigville Motel 12/1/2003 Ellis Septic 8 Shootflying Hill Rd Centerville Craigville Motel 12/1/2003 Ellis Septic 8 Shootflying Hill Rd Centerville Craigville Motel 11/2/2005 Ready Rooter Septic 8 Shootflying Hill Rd Centerville Craigville Motel 11/2/2005 Ready Rooter Septic 8 Shootflying Hill Rd Centerville Craigville Motel 11/2/2005 Ready Rooter Septic 8 Shootflying Hill Rd Centerville Craigville Motel 4/3/2012 Gibbs Septic 8 Shootflying Hill Rd Centerville Craigville Motel 4/3/2012 Gibbs Septic 8 Shootflying Hill Rd Centerville Craigville Motel 5/28/2014 DeBarros Septic Septic 68 , Shootflying Hill Rd Centerville Coelho 7/26/2011 DeBarros Septic Septic 68 Shootflying Hill Rd Centerville Coelho,Marcio 6/20/2012 DeBarros Septic Septic 82 Shootflying Hill Rd Centerville Trought 5/21/2014 JM Barros Septic 109 Shootflying Hill Rd Centerville Childs 3/19/2007 Macomber Septic 115 Shootflying Hill Rd Centerville Macomber 9/8/1999 Macomber Septic 145 Shootflying Hill Rd Centerville Roberts 6/4/2014 JM Banos Septic 157 Shootflying Hill Rd Centerville McLaughlin 12/6/2000 A&B Canco' Septic 157 Shootflying Hill Rd Centerville Averinos 1/5/2004 Bortolotti Septic 157 Shootflying Hill Rd Centerville Averinos 4/29/2008 Bortolotti Septic 157 Shootflying Hill Rd Centerville Averinos 9/2/2010 Bortolotti Septic 157 Shootflying Hill Rd Centerville Averinos 6/16/2014 Bortolotti Septic 169 Shootflying Hill Rd Centerville Fernandes 7/5/2000 Macomber Septic 169 Shootflying Hill Rd Centerville Fernandes 10/17/2006 Macomber Septic 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22-#32) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, 7V)77VV11 use only the tab 1. Inspector: key to move your cursor-do not Dion C. Dugan use the return Name of Inspector key. Dugan Construction my Company Name 1543 Main St. Company Address Brewster MA 02631 City/Town State Zip Code 508-237-3461 Sl#60 Telephone Number License Number 9 Q [: B. Certification y V"" I certify that I have personalty inspected the sewage disposal system at this address and that tie= information reported below is true, accurate and complete as of the time of the inspection. The inspect;p� was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ."I—�6d7e'-11— Inspector's Signature 400, Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22432) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22-#32) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's(dame information is required for every Centerville I MA 02632 8/26/14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass.unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22432) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: �*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/Z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22432) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ N Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered-"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M , 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22-#32) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Z ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): gpd t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts uoTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22432) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011 gal is,0 XtV0 9 ( Y 9 (gpd)): 2012 gal 1,15.9, Detail: 7-o`,4L 14c;TRL Sump pump? ❑ Yes ® No. Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: MOTEL 0 gpd Design flow(based on 310 CMR 15.203): 121 121Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 11 - 1 bdrm hotel rooms I Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22-#32) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 60%currently occupied Date Other(describe below): Two systems; each with 1,000 gal.septic tank; each w 6'x 6'leach pit w/4'stone; no D-Boxes found. General Information Pumping Records: Source of information: see attached Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest Iinspection of the I/A system by system operator under contract f ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22-#32) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: installed: unknown, no records on file at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >50'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints are tight; venting at roof; no signs of leakage Septic Tank(locate on site plan): Depth below grade: 1 p g feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) two tanks: #1 1,000 gal. #2 1,000 gal M If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: see above note 2" Sludge depth: t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "- 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22-#32) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and tees are in good condition; no signs of leakage; Recommend maintenance pumping every 3 yrs. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22432) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is required for every Centerville MA 02632 8/26/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22432) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): no D-Box found at time of inspection. (none) Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.). *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Of6cia)Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 8 Shootflying Hill Rd. Craigville Motel (Left side Rooms#22432) MAP-234 PARCEL-059 Property Address Jitendra B. Patel Trust Owner Owner's Name information is Centerville MA 02632 8/26/14 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: two 6'x 6' pits ® leaching pits number: w/4'stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit#1 found w/42"of liquid in it; Pit#2 found w/39"of liquid in it; no signs of failure. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17