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HomeMy WebLinkAbout0019 MAGNOLIA AVENUE - Health 19 Magnolia Avenue ` Centerville F/R A = 226 142 _ NCB. 152 1/3 O RA a� /0 . i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C- wM ,•'"y 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address II-+ Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name } information is Centerville West H annis ort MA 02632 Jul 11 2016 required for every ( Y p ) Y page. City/Town State Zip Code Date of Inspection i-► td 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, 3 use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, RS use the return key. Name of Inspector Eco-Tech Rapid Response r� Company Name 155 George Ryder Road South Company Address B� Chatham MA 02633 City/Town State Zip Code l 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails �N OF MgsS ❑ Needs F �o AVID �N the Local Approving Authority D C NOUG N R N e�) -- July 11, 2016 Inspector's Sig ur GfSTeVL Date Sq C� The system ins mit a copy of this inspection report to the Approving Authority (Board of Health or DEP)wi I 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 �o �s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address -, Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner . as Owner's Name requir every ation.:is Centerville (West Hyannisport) MA 02632 July 11, 2016 required for Zip Code Date of Inspection page. City/Town State "h B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental ' compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. r *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. h R� ❑ Y ❑ N ❑ ND (Explain below):,i,* t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is t HW ill t Cenerve( es Hyannis port) J required for every y p ) MA 02632 July 11 2016 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is required for every Centerville (West Hyannisport) MA 02632 July 11, 2016 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 y_ colform.bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than b 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is t HW ill t enerve es Hyannis port) MA 02632 Jul required for every C ( Y p ) Y 11 2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is required for every Centerville (West Hyannisport) MA 02632 July 11, 2016 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: ® ❑ 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)] p ) L D. System Information Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 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 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is i t HW ill t Cenerve ( es Hyannis port) u required for every y P ) MA 02632 July 11, 2016 page. . City/Town State Zip Code Date of Inspection D. System Information Description: A system sized for six bedrooms was installed by J.P. Macomber in 1996. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 533 gpd ( Y. g (gpd)): Detail 2014: 197,000 gallons 2015:192,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-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 °M 19 Magnolia Avenue -Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is t HW ill t Cenerve es Hyannis port) MA 02632 Jul 11, 2016 required for every ( Y p ) Y page. City/Town . State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner's agent 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 co of the current operation and gY copy p 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 L W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is t HW ill t Cenerve ( es Hyannis port) Jul required for every y p ) MA 02632 y 11, 2016 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: Age: 20+ years. Certificate of Compliance for a new system was issued 3/22/1996 (Permit#96-86 at Health Department). Septic tank was repositioned in 2004 (Permit#2004-481) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting,evidence of leakage,'etc.): Septic Tank (locate on site plan): Depth below grade: 0.5 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: 2000 gallon Sludge depth: 4 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is Centerville West H annis ort MA 02632 Jul 11, 2016 required for every ( Y p ) Y 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 30 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc..): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is Centerville West H annis ort MA 02632 Jul required for every � Y p ) Y 11 2016 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is Centerville West H annis ort MA 02632 Jul 11 2016 required for every ( Y p ) Y , 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions observed. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is t HW ill t Cenerve ( es Hyannis port) 02632 Jul required for every Y p ) MA Y 11, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Water flowing through the distribution box was observed to pass through in a rapid and unobstructed manner. Permit application of 1996 indicates H-20 units capable of withstanding vehicular loading were installed. 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 l5ins•3113 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 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is required for every Centerville (West Hyannisport) MA 02632 July 11, 2016 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is required for every Centerville(West Hyannisport) MA 02632 July 11, 2016 page. CityTrown 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 LOoCA T§ONS -OF SEPTIC COMPONENTS M nI ra -DISTANCES IN DECIMAL FEET C�/ro§S§ \I G A 8 D WELD NCGs- 1 40 21.5 A 2 38.5 27 3 34 41 B � O n D-BOX rn 2� 2000 GALLON a I SEPTIC TANK rn THIS SKETCH IS BEST VIEWED IN —� COLOR FORMAT m i DRIVEWAY NOT EST SCALE A., 1995 1 . 508 364-0894 1 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is i t HW ill t Cenerve es Hyannis port) July required for every ( y p ) MA 02632 J Y 11, 2016 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: 15+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9/23/2004 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous inspection report ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 15 feet above groundwater table. Previous inspection report on file with the Health Department shows an augur in which no water was encounterted to a depth of 10 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 19 Magnolia Avenue-Assessor's Map 226 Parcel 142 Property Address Stefan Seidner Revocable Trust-Stefan Seidner, Trustee Owner Owner's Name information is HW ill t enerve (West Hyannis port) Jul required for every C � Y p � MA 02632 y 11 2016 page. Cityrrown 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 GEOHYDROLOGICAL PROFILE — NOT TO SCALE PRECAST DRYWELL BOTTOM OF LEACHING GALLERY LEACHING IS ABOVE HIGH GROUNDWATER w O GROUNDWATER ELEVATION PER GIS MAPS t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 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, use only the tab 1. Inspector: Q key to move your cursor-do not JOHN GRACI (� use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS, LLC VQ Company Name PO BOX 2119 Company Address TEATICKET MA 02536 Citylrown State Zip Code 508-641-6694 S1468 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the. information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Fu r Evaluation by the Local Approving Authority 09/30/2013 Inspector's Signatu a Date The system ins ector 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 Insv o Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owners Name information is required for every CENTERVILLE MA 09/30/2013 page. CityrFown 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 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M st 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. Cityrrown 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 y�. 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 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 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 9 9 q 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: NA 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 99 P ❑ ® 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 Y2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A M 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate Lt5m. /13regional office of the Department. /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. City(rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 LtNns3/13 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 M 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2000 GALLON H-20 SEPTIC TANK, DISTRIBUTION BOX AND H-20 8X33 LEACH FIELD Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gP ))� Detail: 2011-220,000 2012-197,000 Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date Commercial/industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. City/rows State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): NA General Information 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: 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 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is CENTERVILLE MA required for every 09/30/2013 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: 09/23/2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: GREATER THAN 10+' feet Comments(on condition of joints, venting, evidence of leakage, etc.):. NO COMMENT Septic Tank(locate on site plan): Depth below grade: 4"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 5" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 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 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUCNTIONING PROPERLY RECOMMED PUMPING EVERY TWO YEARS Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner owners Name information is required for every CENTERVILLE MA 09/30/2013 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: NA 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•3/13 Title 5 Official ins pection 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 , 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. CitylTown 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 BOTTOM OF PIPE 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.): DID NOT EXPOSE DO TO LARGE TREES PLANTED OVER THE D-BOX RECOMMEND REMOVING THE TREES AND RAISING THE COVER 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.): NA *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: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 8X33 per asbuilt ❑ 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.): VIDEO INSPECTED APPEARS FUNCTIONING PROPERLY AND STRUCTUARLLY SOUND. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 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 , 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 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.): NA Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 .\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 page. Cityrrown State Tap 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 AA qD 148 3 so I--C 3q 6611 w 4 . t5ins-3113 Title 5 Offic of fnspecfion Force Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 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: GREATER THE 10 FEET 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: AUGER Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 19 MAGNOLIA AVENUE Property Address STEVEN SEIDNER Owner Owner's Name information is required for every CENTERVILLE MA 09/30/2013 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 r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. FEE COMMONWEALTH OF MASSAC14USETfS Board of Health, A•i7� MA. PPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT plication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System l►lIndividual Components Location Owner's Name Map/Parcel# Address Lot# Telephone# Installer's Name C Designer's Nan- PHEN J.DOYLE.a\D ASSOCIATES Address Address EAST FALMOUTH,MASSACHUSETTS 025M Telephone# Telephone# Type of Building / Lot Size '30 5 29 sq.ft. ZDwellin No.of Bedrooms �, ((� Garage grinder ( ) r-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) �o(�,n gpd Calculated design flow 640 _ Design flow provided 49-7 gpd Plan: Date (, — Number of sheets Revision Date —f)ZL Title T�`� n �c�.�0� c�l� �Q t� A \ 1 A {/ M' !k— Description of Soils) ��`�,�V k xs ,®�ygt � & 6_� Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONST�A�r/ fie . _ —AGA9 The undersig n agrees to install the above described Individual Sewage Disposal gr g p System m accordance with the provisions of TITLE 5 and further a e s t n to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date No+"' a FEE ETA `v Board of„Health, ' q�y �A_�c, MA. �p �PLIC �M FOP DISPOSAL SYSTEM CONSTRUTION PERMIT ppli6ion for a Permit to Construct(*) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System /Idividual Components Location , � Owner's Name Map/Parcel# Address Lot# Telephone# Installer's Name C . Designer's NaWPHEN J.DOYLE AND ASSOCUTES Address Address UST FALMOUTH,MASSACHU.§gTTS 0206 } Telephone# Telephone# Type of Building // Lot Size SS D sq.ft. Dwellin -No.of Bedrooms �L� Gartage grinder i l ( ) rt r-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) G(g n gpd Calculated design flow L L Design flow provided ��� gpd Plan: Date bC4r— Number of sheets ^ Revision Date, ,` G �+ , Title ,n�,�, o 1�.� �/l A a \Q i1�„ �►1�Coin S�"E � ��b Description of Soil(s) i Soil Evaluator Form No. Name of Soil Evaluator \Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersign ,d agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire s t n9tito place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signedx / Dates I.nspect� ns r No. ' FEE COMMONWEALTH OUS�ETTS Board of Health, T4M, MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned Ahereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned O •." by: at l G1 Am A lq l G C?^ M//I has been installed its accordance with the provisio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. W YV , dated 9 MIA)L/ . Approved Design Flow 6 60 (gpd) Installer A w i. I 1 J Designer: Inspector: 0L,4 < Date: ,D 1 )4 104, The issuance of�this permit shall not be construed as a guarantee that the system will function as designed. + l� "x No. /�r FEE C®MMONWEALT"OFASSAC141USETTS Board of Health, . MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permiss•on i hereb granted�; Constr�uf t( ) Repair( Up rade( ) Abandon( ) an individual sewage disposal system at ��©U� V 6a /V 1 ZVILLC as described in the application for Disposal System Construction Permit No. / dated Provided: Construction shall be completed wit in thr e years of the date is r ' . All 1 al conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date -oard df�Health Town of Barnstable Regulatory Services Thomas F.Geiler,Director enexsreei8. Public Health Division 1639. ct9' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: y a3_oy Sewage Permit# o?041- '/f/ Assessor's Map\Parcel �dtgfkl/�' ,l�y vae4' D" U, C. / i l/ 0 „1A9t P`: &TEP EN r POV4 r .NWASSOCIATES 42 CANTERBURY LANE Address: If 9 Address: UffFALMOUTH,MASSACHItSETTS 026M 508/640.2534 On was issued a permit to install a (date) (installer) septic system at �Qtl A( &i tA, 1i'� based on a design drawn by (address) ASbgc, dated (designe ) V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ®®tsAeadQ OF 14"SSA (Installer's Signature) c P� �`- � o STEPHEN � U J. ® DOYLE P. ® f3 0 ~JFc �F A (Desi er's ignature) (A o®V ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc TOWN OF BA,RNSTABLE LOCATION ,,Wo SEWAGE # VILLAGE X e ASSESSOR'S MAP& LOT!—!?! INSTALLER'S.NAME&PHONE NO. T C ya J. SEPTIC TANK CAPACITY oz V a q //.?,D LEACHING FACILITY: (types Fx f�•^> ;3 3 rJ rr��� . ��(size) NO.OF BEDROOMS - BUILDER O OWNE _ S;cols fr- PERMTTDATE: 9`—;Z 3— ®L/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 i w 3f . 134.1 2 7 �- y TOWN OF BARNSTABLE L'OCAHON SEWAGE :a gpOH VILLAGE L�-, ��.w����' ASSESSOR'S MAP &LOTS INSTALLER'S NAME&PHONE NO. �T C. �� �1`9 (.SoE) SEPTIC TANK CAPACITY d���✓� 1�07 LEACHING FACILITY: (type) > 4. (size) NO.OFBEDROOMS r B 44 DER O OWNE Sir-/- tr PERMITDATE: _>r�3— O'-I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 F' 0 �1 � No. A. Fee 0.00 m A THE COMMONWEALTH OF MASSACHUSETT de PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for �Diz pogaf *pgtem Conotruction Permit Application is hereby made for a Permit to Construct( )or RepairXX)i an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 19 Magnolia Ave Steve Sedner West Hyq_nnJs:port,Mass . Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber Jr. 508-775-3338 J.P.Macomber Jr. Box 66 Centerville,Mass . 02632 Type of Building: Dwelling No.of Bedrooms 6 Garbage GrinderP ) Other Type of Building Res No. of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 660 gallons per day. Calculated daily flow 3t1 1 0=330 gallons. Plan Date 3/20/96 Number of sheets Revision Date Title Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Omit cesspools. Install 1?R000 gallon 1-distribution box 8 330 H2O rechargers packed in stone 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 Certifi- cate of Compliance has been iss ed by this d ea t Signed Date3/20/96 Application Approved b Application Disapproved for the fo owing reasons Permit No. Date Issued _19zS m—�C No. ,� Fee 0.0 0 THE COMMONWEALTH OF MASSACHUSE17 de m ; PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPItratton for �Digool *p5tem Con!5trurtton vermtt Application is hereby made for a Permit to Construct( )or RepairXXX an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 19, Magnolia Ave Steve Sedner - West Hyannisport,Mass. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J.P.Macomber Jr. 508-775-3338 508-775-3338 - J.P.Macomber Jr. Box 66 Centerville,Mass . 02632 Type of Building: Dwelling No.of Bedrooms 6 Garbage GrinderP ) Other Type of Building Res No. of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 660 gallons per day. Calculated daily flow 3t110=33 0 gallons. Plan Date 3/20/96 Number of sheets Revision Date Title Description of Soil Sand Nature of Repairs or Alterations(Answer�yhen applicable) Omit .CeSsp001s. Install 1)2000 gallon s-crptic L---k, 1-distribution box 8 330 H2O rechargers packed in stone 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 ofTitle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo d o f t f Signed Date3 20/96 Application Approved.b + Application Disapproved for the fo owing reasons '` — Permit No. Date Issued 62 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Corr pl ante - - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replacedU)D on3!2 n/9 6 by J.P.Macomber Jr. for Steve Sedner as 119 Magnolia Ave W. H.yannispoiet,Mass/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. v d date �g. 9G " Use of this system is conditioned on compliance with the provisions set forth below: No. — Fee 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=igpoga1 *pgtem Con5trurtiou Vermtt Permission is hereby granted to J.P.Macomber Jr. to construct( )repair tXA an On-site Sewage System located at 19 Magnolia Ave West Hyannisport,Mass. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: 96 Approved by \A, ,� r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) b I, Joseph P. Macomber Jr,.hereby certify that the application for disposal works construction permit signed by me dated 3/20/96 , concerning the p operty located at 19 Magnolia W. Hyannisport meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet Qf the proposed septic system • The observed groundwater table is 4 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIG DATE: LICE ED 4SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i TOWN OF BARNSTABLE LOCATION /'P � �� !)'/ � SEWAGE # ' VILLAGE 40 T Lev ' ASSESSOR'S MAP & LOT r�lvs y9�cTpv� ^-� 0i FAt='S NAME&PHONE NO. V f SEPTIC TANK CAPACITY IUD LEACHING FACILITY: (type) ��� (size) NO.OF BEDROOMS BUILDER OR OWNER ��: �� � Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 f any etlands exist within 300 feet leaching fac ty) Feet Furnished by �-�;�� �: s _ � �,� �:A �. . . ` ,1 ; / V• PROPERTY ADDRESS: 1-9 Magnolia 'Ave ASSESSORS MAP N0, Centerville, PARCEL NO' /4 Mass . a s On the above date, 1 inspected the septic system at the above a r , This system consists of the following: 1 .-• 1=41W cesspool. 2 Based on my Inso ctlon, I certify the following conditions: 1 . This is not a title five septic''syst,gz. 2.Th3,�a-is 'a sewage-' .system'. Single cesspool. 3.••. The sewage system is .in failure . ;.;►::. ). 4.. Must- be upgraded to a .titleo five septic sys tcm ; SIGNATURE: Company:J•P_Macomber & Sonr_Inc. r Address: Centerville JjAps : -G2.632 ' Phone:---SQ87-5�3338------- - 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON,. INC. Tanks-Cesspools-Leachtlelds . Pump*d & Installed Town Sewer Connectlons i P.O. Box 66' Centerville, MA 02632-0066 77•5.3338 77"412 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Ilam F.WNdGoarnor Trudy Coxe Argeo Paul Celluocl 8 "*WY ILL Oovemor David B.Struhs • Cart M1881w r • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION Property Address; 19 Magnolia Ave Centerville ,Mass .Address of Owner. Date of Inspection: 2/13/9 6 (If different) NameofInspector. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true and . Po ,accurate complete as of the time of inspection. The uis ion was pact performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _- Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority is Inspector's Stgnat �'"� • Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)clap 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: . ,2 6 I have sot found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: >D One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain wby not) N044 The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exflltration,-or tank failure is immin nt. The system will Pass inspection if the existing septic tank is replaced with a poaforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02108 a FAX(617)SWI049 • Telephone(611)m-SS00 i Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 Magnolia Ave Centerville,Mass . Owner. Robert Hall Date of Inspeotion: 2/13/9 6 B]SYSTEM CONDITIONALLY PASSES(continued) iva bex Se ' wage backup or breakout or h�h static water level observed in the di&trIbutioa ban is due to broken or obstructed pipes) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(g)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: . VP Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: &19 Cesspool or privy is within 60 feet of a surface water d1P Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: �Q The system has a septic tank and soil absorption system and is within 100 feet to,a surface water supply or tributary to a surface water supply. d& The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. A20 The system has a septic tank and soil absorption system and is within•60 feet of a private water supply well. The system has a septic tank and&oil absorption system and is less than 100 feet but b0 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lea than 6 ppm. 3) OTHER (revised 11/03/95) 2 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddre..: 19 Magnolia Ave Centerville,Mass . Owner. Robert Hall Date of Inspeatlon: 2/1 3/9 6 D) SYS FAILS: s I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. AW Backup of sewage into facility or system component due to an 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. LJ�quid depth in cesspool is less t�6"below invert or available volume is less than 1/2 day flow. t��a /W77-0A4 0 f Nb Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped �Q Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. d& Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. J� Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public WSW supply well) The owner or operator of any such system sball bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Author information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 Magnolia Ave Centerville,Mass . Owner. Robert Hall Date of Inspection: 2/1 3/9 6 ' Check if the following have been done: --Pumping information was requested of the owner,occupant,and Board of Health. ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A&As built plans have been obtained and examined. Note if they are not available with N/A. .r _eThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow VThs site was inspected for signs of breakout. • All system components,9duding the Soil Absorption System,have been located on the site. NO 7o4&The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baflea or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants,if different from owner)were provided with information on the proper maintenanoe of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 Magnolia Ave Centerville ,Mass. Owner. Robert Hall Date of Inspection: 2/1 3/9.6 FLOW CONDITIONS ID s Design flow: e dr Number of beooms:. Number of current residents: VWMT Garbage grinder(Yee or no): , Laundry connected to Syas or no):A Seasonal use(Yea or no water meter readings,if available: Last date of occupanry:• V4VA-' COMMERCIALANDUSTRIAL• Type of establishment:��al� Design flow: #31q _gallons/day Grease trap present:(Yes or no)AB Industrial Waste Holding Tank present:(yes or no) lO Non-sanitary waste discharged to the Title 6 system: (yes or no)al Water meter readings,if available: AM Z 1: r Last date of oocupancy:_AJ&_ OTHER(Describe) AI A Last date of occupancy: AAA GENERAL INFORMATION PUMPING ORDS and source o4 iqformation: System pumped as part of inspection:(yes or no),db If yes,volume pumped: zb gallons Reason for pumping: Alt? TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool A)A Overnow cesspool Privy Shared system(yes or no) (if yea,attach previous inspection records,if any) AIA Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: L10 + y-eAd' Sewage'odors detected when arriving at the site:(yes or no)_ (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART C SYSTEM INFORMATION(continued) Property Address: 19 Magnolia Ave Centerville,Mass . Owner. Robert Hall Date of Inspection: 2/1 3/9 6 SEPTIC TANI{:A2dV , e (locate on site plan) Depth below Vade:A - Material of ooustructio concrete_metal FRP­other(explain) Dimensions: Sludge AM Distance fiom top of sludge to bottom of outlet tee or baffle: _ Scum thiclmess:'_ Distance from top of scum to top of outlet tee or baffle: 44 Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation r pumping,conditionf of inlet an d outlet tees or battles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.)• No GREASE TRAP: Qq�le— (locate on site plan) Depth below grade:, Material of construction ncrete metal_FRPZAN other(ezplain) Dimensions: Scum thiclmess: Distance from top of scum to top of outlet tee or baf le:129- Distance from bottom of scum to bottom of outlet tee or be.M9 2 Comments: (recommendation for pumping,condition of inlet and outlet tees or baMes,depth of liquid level in relation to outlet invert,structural integrity, evidence o lea�a�, (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(oontinued) Property Address;* 19 Magnolia Ave Centerville,Mass . Owner. Robert Hall Date of In•peotion: 2/1 3/9 6 TIGHT OR HOLDING TANx-L4y-" • (locate an site plaa) • Depth below grade: Material of oonstrudiony(�ooace ete metal_FRP_other(explain) AIR Dimensions: AIA Desiga flow: ns/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Pei mmerv'r5 DISTRIBUTION BOX:.&)-O qj e (locate on site plan) Depth of liquid level above outlet invert: Ili ig Comments: (note if and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBEPLA&� (locate on site plea) Pumps in working o:der:(yes or no)- Comments: (note condign of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 all SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Magnolia Ave Centerville,Mass. owner. Robert Hall Date of Inspection: 2/1 3/9 6 SOIL ABSORPTION SYSTEM(SAS): (locate an site plan,if possw ;ssoavation not requiV4 but may be approximated by non iatrusive methods) ' If not determined to be present,esplain: e leaching pits,number._D leaching chambers,number. leaching galleries,number leaching trenches,number,length:_ leaching fields,number,dipions: overflow cesspool,number. V (o ents:(note condition of soil,signs of hydraulic failure,level of pouding,condition of vagetation,etc.) CESSPOOLS: (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: MV' Indication of groundwater. inflow(cesspool must be pumped as part of inspection) Co to:(pote condition of soil,signs of hy4raulic failure,level o ponding,condition of vegetation, .) �r - /y e PRIVY: (locate on site plan) . Material-of oo AM Dimensions:_ N,4 Depth of solids: Co ts:(note condition of soil,signs of hydraulic fail re,level of pondin&condition of vegetation,etc.) W14 No Cd na j44 ems)�r S (revised 11/03/95). 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Magnolia Ave Centerville ,Mass . Owner. Robert Hall Date of Inspection: 2/1 3/9 6 e SKETCH OF SEWAGE DISPOSAL SYSTEM: . • lacluda ties to at least two permanent references landmarks or benchmarks locato all wells within 100' 01 J O S • DEPTH TO GROUNDWATER Depth to voundwater:IL�—feet method of n or ap rozimatio (revised 11/03/95) 9 r Y r 4 � •ennt•+r —nrsr—•trtirnramnts.s�anrrai*rrrraszs++•ervtri�rrsnrr*+m-rrc+rra�►enera+ •. •r�•��.��.r— TOWN OF Ra rn at A hl P BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION 1/ �"•4M-T•:•5.7—T.t i1f'ST.TTVniT1•R:MIT{1f'iQTt/7TTT'Tt•t!i1T119R17CP•TRTRtRttJ�flRY117riltl!'fOf'i toil R7r•t-•TT•-11•- -TYPL OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 19 Maannl in Aire r..ant.arvi 11 JPJ�Mgsus _ ASSESSORS MAP, FLOCK AND PARCEL # e OWNER' S NAME Rahert. Hail PART D - CERTIFICATION Omuta NAME OF INSPECTOR Joseph P_ Mnnnm'her Jr. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS' Box 66 Centerville ,Mass . 02632 Street Town or City State Lip - COMPANY TELEPHONE ( �('�� ) 775 3338 FAX ( 508 � 790 - 1578 tt■n an,r v�si+rnet cta�ea a�addda}Qaizo R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a this address and that the information reported is true , accurate, and complete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenr;tnce , and repair are consistent with my training and experience in the proper function and maintenance of on site sewage disposal systems . Check one: ' System PASSED ' The inspection ;which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 151303t Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title a , 310 CMR 16 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature ADate One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the DOARD OF 11RALTIt. * If the inspection FAILED, the owner or."operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . ' M v b . S ,tip THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the..Department's qualifications as required and-is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Depa_rtroent of Environmental Protection. June 8. 1995 ` r Acting Director of the • ion of Water Pollution Control --e �. oil2�xa O a TOWN OF BARNSTABLE LOCATION 1 SEWAGE # VILLAGE V ASSESSOR'S MAP & LOT :2 a(b INSTALLER'S NAME&PHONE NO -► Y Vle4Cep1M:h 53P'TIC TANK CAPACITY a92 Q O Ut&CHING FACILITY: (type) tin� n� �_ (size) NO,OF BEDROOMS Ii NLDER OR OWNER PERMTTDATE: . COMPLIANCE DATE: -a Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �� \� ./ � // �; �� � � i � � �� ��. � �� �� � / ��_ �/ _� sa -- /- n1 s ., !✓ r' o. o 0'-I 19/16• Ii•b.U3Z• D'-113/IB' II'-I^ --------------- ----------------- . q ------------- --------- 3'-0 5/Ib' 4'-II 21(52' 9'-6 9/Ib' IT 3 9I'-0• 13'-Y q. 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H in 9 c o FAMILY ROOM ;:J ________________________ a', DINING ROOM ;I u m i 4 - W) LIVIN6 ROOM ly A rb KALL S'D 4^ S'-9 V4• ! i0 S In' 8'-6 In• II'-I• Q �'-0 IM 9 In• 9'-6^ 9'-7 in" 3'-I' S 1!Y m +V P q A sIn DIn oLON IZ HALL 6 Ly o€ sP3 ry Sff2 " + �� a�OggEfi . oa a - m ff 8'SR 2 T. a;Lq ��agp5 K m m t 1 1 - S In' •-8 V li O I.,STEP m W w 12•DIq FA.COL. 6 • J GUE5T BEDROOM E - m �J Q ry n Q +t r1 L 11 1 W �- - � ♦ 11^J t- b "T � 1 (� 2'-I' '-I 1(2" 6 'J •• s In• � 11 i U Y LU q O T J n ENTRY PORCH �* _ n J 0_ 3 2: MILL 4T a ISTOIE RIMS ' L4J J O Q N El L ry 4•-2' T'-O' T-T $W a•-I' 0 Z f f� LL e•-2 514' s•-4 Va. a'_y B W REEZEAY 9 N I Dlq Fb.COL. a T-S' 4'-9' 51-9 I/4' 518 9/4• W��( �'J In" 6'-O' b'-D• 4T 9 U 1 a LL 121-0' 19'-6' •lob no.: 'M61 L6- Y aam .Lt&2.2003 FIRST FLOOR PLAN A9 NOTED SC A LE 1/ 4" 1 - O' PAN A -2 WINDOW 8 EXTEP-10R DOOM SGF 4EDULE STM.TYPE pESCRIPTION FUX"OPEWN& NOTE FF° PJ Q A CPA-*2S DOIELE KM 3AVS'X9-5' M m •,« S Op14SlJD OCt6Y NKa A-I't/D'X R1' M I a ct,2m VOA"NIt6 2A1W x94' 6A 2 0 CVM-2E24 VOMZ KM 21-5,W xV-V bn 4 E CptF2426 OaeLE Km 3'4V6'%S'H' bA 3 P Oa62404 OOIELE NNb 24 W X 4A" 6A 10 O CVW2422 OGRE NNB 241M•x Nix 6A b N CVN 202S OOLEI.E 1cT4S 24 1W x 54' 44 2 r'y I�` i x I 001.702b Vag"RM 2'-I VD'X5'i' 411 2 C0MF2a5 OQAE KM T4 VW X S'-9' M 3 K C 2046 CA`AKW 2+4 W X 4.4 V7 TTP. 3 L CG-2030 GASMW rA V2'XV-50' TtP. 7 1 I M CM-2424 MOO 215WX2-SV2' 1". 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I 4 O°a•59066iOXKt1(Ol LMOLN•SNMS PATIO WOR 6'A 3/6'X b'-T so- TTP. I M 1 C £ E S SA7 5PP5011 21V 1/4'X b'-6 UH" 2-RI64T K*V FLEFT WV 5 _ 41d' 3' 33'- 6 5-0 66PSOR .10 V4-X 6'-b 1/V LEFT N41JD I •E,t --'_7 „ I O O w O O T TF99066 LMWINFtff2YM ODOR 5'-W IV16'X 6'•T S✓b' LEFT-AOTNE RI6NT-PASSIVE I _____ 6 CFSS466 LRKOLN•FROK,N DOOR S'_2 IVI6'X b'-7 S/D' LEFT•AGTVE RIOeiT-PA551VE I r1 m i F S f HALDER 1b VT30FT GU MNTT OP EACH TTFE Of APItt+N MID DQOR a ,_.JX pt�1 T-ALL NINDwb TO WL1NC0LN Y4tTE ALIRL 0.AD,LIXt-E AR60N PALLED 6LA�i N - r � , , m -W NMAATM OMOED L161R MMTW,,MITE SCREVY,5TAMARP NARDNARE - , n :Q It o % MASTER BEDROOM ? BEDROOM#1 v BEDROOM R2 ROOM*3 - _ - Y _ P C F W l'g1j6y� Y I'A TAb'9'-5 I '-0 W'-O' � w 9'-]VY 7�8• 7'•2 In' 9'-1" 2-Bx6 FLO W.I G.4 a L vw ruw. UPPER HALL 3 5-0' 4•-0 w P a 1 99�6^TqIL.JL. 1'-6 9A6' ppST p�W ILA RA lIN6 PROM g 60JE W _.{ ++ H.. I `OPEN TO 13e-or'" 900KS 600" s V' A. \•/y •'(U W $ .•1 Sri' __- \J/ U zIN - LLI Q LL �' ddii jj J S•101AW 4•-9 11 5 1/2'LOFT Z S'4 (IL SEAT 9' _ m T 9 A-1 A C J�ro.: 9961 dNa - J/NE 2 2003 1 AS NOTED _c. 10 moon PAM rN. S E C O N D F L O O R F L A N N m S C A L E: 1/4' A-3 • N VJ 4 Q = L U � BREEZEWAY _ 0 ° 2'_y a•-a' S'-9 I/4' YES 9/4• ] r r ` .a. 'p F A '•`� ° 10 • r L .� t , lY � a J uP e Li m m __________________________________ - r h T - i ' I '__________ P.T l I ' .STEP °V 2-GAR GAR E c on F- VNExOAVATED S Jn' 9'-4 I/93" 0'!IS/92' in' 10'-61n' 5,2• 4 2-o xcan-gyp.pA�Plitp°�NpQS x n h (j����([�,'�/J�/jam//►► YV TR/J190M3 ABOVE m V 'A DROP TOP OF HALL _ I I __________ __• Al2 439TER BM.I x Q Q „4 S 4 IT DORMITORY ^' o , , , � n n I ��g�'•a�kLS g i °i v $Pas a�136 x6 P°x - w I Q , s T = v n W , W 13 X 30 STEEL BM. NORKBENOWC0UITER �p w n n n Q ---- ------tt- -----t 2'O' 30'-O• 2'-0' a D � V LU 34-0 M M N w - z N 3•-9• 4•-W 4'$, 4•-(" S•"3, 5-2' 4-8• 4�• 4"°. 5-2• Q J Z O Q Q N F O U N D A T I O N P L A N F I R S T F L O G R F L A N S E C O N D F L O O R P L A N S C A L E : i/ q ' = 1— O' S C A L E : 1/ 4' = 1'- O' S C P L E I/4 = I'- O' - Jab ro.: 9461 deb XkE Z 2003 x4b AS NOTED d e W PAN feN. fCV. A-4 r Top Foundation Elev. 175' CENTERMLE ROUTE 28 Finish Crade EL IB't s`r Foundation 6„ 6„ /,////„/ ' llllllllllllllJ P f-lllillllllll, c� � Design By others NVM; MAR � 15.0' DVia 0 D}a 10'wn 14•Afia -•--Tap Existing Distribution Box4wt �� --► To Existing (6) Bedroom Leaching Facility INV EL14.5' -\mow�O'�Line 1 ump (8) 330 H2O Rechargers in Stone Trench Liquid �. Per Barnstable Sewage Permit ,Y96-86 4 :8" Stone: . Dj `C7 4 HOLE DI,1>TRIBUTION BOX ACK KC� BE 2000 GALLON SEPTIC TANK - H2O LOAD CF) LOCUS x a 2000 GALLON REINFORCED CONCRETE SEPTIC TANK - H2O LOAD yeG`E"' NANTUC"T SOUND Minimum Construction Materials Per 310CMR 15.226(2) \ LOCHS MAP Tees shall be constructed of Schedule 40 PVC and shall extend a . minimum of 6" above the flow line of the septic tank and be on the centerline of the septic tank located directly under the �1 a W#7A clean-out .manhole. The inlet pipe elevation shall be no less than 2" nor more than 3" a�ya above the invert elevation of the outlet pipe. � �� oo ronot 1tirrr i PLAN REF 12134B, 373190 & 34191 0 1 . Septic tank shall be installed level and true to grade on a le vel, p� 10 %4 11 A sq rz• / ....... ZONING.- RD-1 SETBACKS.- 30-10-10 rn_stable base that has been mechanically compacted and on which ASSESSORS MAP 226 PAR 142 G ��xA ° ""••••'• / � 6 of crushed stone has been placed to ensure stability and p Eoluo � I OVERLAY DISTRICT AP to prevent se t fling. �1S Soll Eo�4A ED13/''�1 ._ PORTroN OF FEMA ZONE "A13" (Base Flood El12.0) „ nit• LOT 224 Septic tank shall have a minimum cover of 9 . Inane CB/DH FIRM PANEL 250001 0008 D (Rev 7102192) Two 20' manholes with readily removable impermeable covers /�� `� WETLAND FLAGS BY "ENSR" �nrrrso�r Plt/ 4j / of durable material shall be provided with access ports <1 ::;_:_• . -' DEP Coastal Baz+k:.; :::....::. Proposed The outlet tee shall be equipped with gas baffle. �"' t?°°b T1A and )r°rk Limit 6 • ose y 6 :. :::::::::: 0 Fb1P8 1�'NA Lin �. and Silt Berrien DFA .. .::::::.': Edge or Lawn • ..:...:..:.... 2 w ya y \V aYlli3 Line IA t� o IsYlWU T 22 Qj © 1OJI4 `o T4A a 14:L off° 1�1►3 N tagrual TO BE �`_ >r 4� t; Jl_ Vegetation j j \ RAZED169 ' Pit , �� 2 �89 16.49 1352 P91Iz (� , T4B PROPOSED. EDV T < 0 0 g ,- \ 4J Pa 27B 728 T3B T4B ::: Y' o .. 6// O t bl. • g o o_ o- lg 5 \�./ 0 1 g PROP o_ 10 5 \\\(PLAN 373/90) EL 6.0' EL 10.5' EL ISt 2' EL 16.1 !,� T1 �� 15' �, 5' ON 0 N00 04 7'10"E DUNSMT LINE 1B / �'JAS/LOT 142 .� 1 �',I,•� 6 , 2z� _ \ , Scale.* 1' = 30' T18 �.- U' ram, . Scale.* \ 7,2 00 � TOTAL AREA \ Septi ,. � � � CB/DH •"`,I hws 39,350Q4-SQ.FT. Line 1a No7 LOT 222 I \ 19 221 VARIATIONS BETMN 7VWN GLS DATA AND FIELD To\1`n"zstable' DRI WAS' LOT 219 • a �� SURVEY DATA RA nWT A DISCONTINUOUS BANK and DEP Coastal :: : _:.•, i �� ALONG afAGNOLIA AVE ' Ba 49 LOT 218 .., \ �� �•. I Transact ' �• �' '� � \ � �i �` '•�21$ 29 Line 1 22� % �S. `-- 27 9.99 15.60 BY P 4 91 4L '(BY T4 MAGNOLIA A5PhrALT _ A VENUE --_-�� ------ BENCHMARK- Plan of Land at 19 Magnolia Avenue w ELEV=16.6 TRANSE�C?'LINE 1 2000 Gallon M► A,4 �kL[H Ofi� Prepared For. Neyv TOP OF WATER I,Ae�a 4 p Scale• 1, = 30' � MANHOLE " �k°�':'�s, ' C' +s STE'FAN & CYNTHIA SEIDNER Se tic Tank c + s9 p DATUM NG � c c Location o ��,5"cR�C 5` q'N/o WiLLI `ems ti (H20 Load) .j o QSTEPHEN ` ►► /E 1RMAf m ► In °pYLE Cen t er vlll e Ma ssa ch use t is ,y a q r� a • 0 - `° �i►�I FNG Scale: 1" = 30' Date: January 6, 2004 26�2Dx 15% GRAPHIC SCALE V. ® ®� t � � OA y � 1x Prepared B . 30 0 15 30 so 120 StePhen J Doyle and Associates I zaz9 17 M =15 1 1 42 Canterbury Lane, E. Falmouth, MA 02536 Tl T4 27A TZA TEA T4A Telephone.- 508/540-2534 EL 6.4' EL 7:4' m ia5' EL 15.2' ( IN FEET ) -�c v-s� i o ra S_z TRANSECT LINE 1 PER BARNSPABLE CLS DATA Scale: 1" = 30' . TRAPSWT LINE IA 1 inch = 30 M 3 09-13-04 septic tank relocation r Scale.• 1' = 80' 2 06-21-04 move proposed dwelling 1 03-02-04 add wetland data NO. DATE DESCRIPTION