Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0095 STANLEY WAY - Health
95 Stanley Way Centerville A=228-116' J��uo► Imc4b 0.2153L0� No..----`� F��... .......:............. THE COMMONWEALTH OF MASSACHUSETTS 43 BOARD OF HEALTH �4- _ Appliratiun -fur 43i"wiat 19orko Tatuitrurttun Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at -- fIrp L � or Lo.......•. ....................... --•---• •.•••�......•• - -'----• n-Addre ' sAddre C C Installer Address QType of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Buildin No. of persons______________•----_.___--_- Showers — Cafeteria a' Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow.........................................---gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width------------...- Diameter---------------- Depth---------------- x Disposal Trench—No- ____________________ Width-------------------- Total Length_-_--__-_-__--_.--.- Total leaching arm...............-----sq. ft. Seepage Pit No..................... Diameter...........--------- Depth below inlet.................... Total leaching area.-__---.---_-____-sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------------........... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------.-------- -------------------------------------- --- 0 Descri tion of Soil----.---.---•------------------------------------ ._ Pi't- ------------------------------------------------------------------- ----------- --------- X ' U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------••-•-•-••--.........------. W -------------------------------------------------------------------------------------------------------------------------------------- `-------------------------------------- --- -- ---------- U Nature of Repairs or Alterations—Answer when applicable...__ ----. - --------------- -------------------- --- - -- --•----------------------------------------------------------�--------•-� - ._. ___ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. I Si --------- ---- -- •-----•- - -•-- ---------------------------. ................................ Date Application Approved By................ . Date Application Disapproved for the following reasons:...........................................................7-.1 ....------------------------------------------- Date......................................... -----•-------------------------------------------------------------•-------------------------------------•••---•-------------------.....------•--•- •••--- PermitNo......................................................... Issued.-• /D.e --- ------------- YM;r .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......OF......... .......... Apphration -fur ]i,ipn ial Work.6 T ato4rurtinn Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: "' r .., { : ..- �' '' LQca on-Address, or Lo N . Own�1 Address ............ .. ........... ........................ ...........__ _____________..__..__. __..................._._._..__..........___..._.___...____. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling 427No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ----------------------------- No, of persons-...____-_-_______----_-:--- Showers ( ) — Cafeteria ( ) a' Other fixtures -----------------•-------------- - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. Septic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth---------------- Disposal Trench—No_ ____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..---__-..-___-.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY--------- ---------------------------------------------------------------- Date---------------------------------------- Test Pit No. I..............:.minutes per inch Depth of "lest Pit.................... Depth to ground water...-_-----_.--.--.------ (J, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ------------------ - ------------------ O Description of Soil---------- --------•--------------'•--•-•-•---• t ;;;ram- ga --------------------_-......................... U .: .F, ---------------- -------;-------------------------------------------- ------------- ---------------- ----------- ----------------------------- --- -- ------ V Nature of Repairs or Alterations—Answer'when applicable j __ .- �_ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued-by the board of health. Sighed - --- ------ ----------------------- ------- "Y Date APPlication Approved BY = - ;;F "%'/ .............: . ---------------- Date Application Disapproved for the following reasons---------------------------------•------------------------ -----------------------••---•-------•---- --------••---•-•------------•---•--------•------------- ----•-------•-------------------•-----•--------------------•--- --t:----- - •` Date PermitNo......................................................... Issued4-/✓ .------•--•-•-------'--•-'- / Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,. ......y/J° .OF........... �. :✓>Yaer8'? ....�................................. Trrttfirate rrf ( amliltaurr THI ,1S CE IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired {�)`~ -- - -- ------------------- Installer at---------•----------------------------•-----------------------------••--------------•---------•-------------------------------------------------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....--------------- ___ ;�__- dated................................................ THE ISSUANCE OF jTHIS CERTIFICATE SHALL NOT BE CO STRUED AS,A GUARANTEE THAT THE SYSTEM )ffj ftCTI ATISFACTORY.to A���t e,& �-4 - '" f �O t ILI I A6 DATE ••---- ---------------------•-•---------_.. Inspecto THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF, HEALTH ...OF........ .......... ,��• ....�.��^:: '"'^Z.:...'� ......". •"t gr No. FEE ,4 ^' -�t����ttlnr� � ��rttr#matt � �rnttf Permission is hereby granted----- --`----------- ,e_oo -- -------------------------------------------------------•- to ConstruT .( ) or Repair ( � Iiidiv>ofxal Sewage Disposal System at No.......-= r ......... Street -as shown on the application for DisposarWorks Construction P e mNo i__. Date, ---- e �. " Board of Health DATE y ---------------•---•' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - TOWN OF BARNSTABLE LOCATION 9S oau-Y\W'/ Wa-J SEWAGE# VILLAGE 12i/1'C sc(J��k' ASSESSOR'S M/AP&PARCEL 'IN19.� S NAME&PHONE NO l Jl SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 50 �J 66vKW--- (size) NO.OF BEDROOMS OWNER Z A A PERMIT DATE: CQMRbbW@E DATE: 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 1 1 9 1 4 33 Water Service 23 40 ,�•s 41 qy , Stanley Way 'Commonwealth of Massachusetts H Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Stanley Way`, Centerville MA 02632 Property Address John Felegiah y��ISJ Owner Owner's Name information is PO BOX 719 required for Centerville MA 02632 January 8, 2008 every page. Clty/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling oi.!! A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name F r� 189 Cammett Road Company Address Marstons Mills MA d2648 �- Clty/Town State CYZiipCode 58428-1779 -- c Telephone Number License Number ?( �, B. Certification co c:� rn I certify that I have personally inspected the sewage disposal system at this address a d 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 ❑ Cvndiiiinaiiy P�sseS j Fails ❑ Needs Further Evaluation by the Local Approving Authority � t'1� � 'l. Januar 8, 2008 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. 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is PO Box 719 re wired for Centerville MA 02632 January 8, 2008 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: Tank is not in need of pumping at this time, leaching chambers were empty at time of inspection with a stain line indicating chambers have never had more than 2-3"of standing water. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not 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,exist n tz nk is replaced .v th a co ip,yl�g septuic ink-as approved by the Board of Health. ' A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-03 Felegian.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 'Comrhonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is required for PO Box 719, Centerville MA 02632 January 8, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 pubiic 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 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. 08-03 Felegian.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 15 Comrfonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owners Name information is PO Box 719, Centerville required for MA 02632 _January 8, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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_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. OM3 Felegian.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is PO Box 719, Centerville required for _ MA 02632 January 8, 2008 every page. Cltylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cent): Yes No ❑ ® 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. 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is p0 Box 719 required for , Centerville MA 02632 January 8, 2008 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must in "ye,' 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 raintenance of s.ubsurr'ace 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)] 08-03 Felegian.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 'Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is required for PO Box 719, Centerville MA 02632 January 8, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 180,000 gal. _ 247 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied 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: Last date of occupancy/use: Date Other(describe): 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is PO Box 719 required for , Centerville MA 02632 January 8, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank has not been pumped 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Permit date: 8/16/05 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is PO Box 719, Centerville MA 02632 January 8, 2008 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: 0 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.): Septic Tank(locate on site plan): Depth below grade: 6 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: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0" 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? Visual 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is required for PO Box 719, Centerville MA 02632 January 8, 2008 every page. Cityrrown 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.): Tank has liquid only no solids. Liquid level was found at bottom of outlet invert and tees were intact and clear. 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.): 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 El other(explain): 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is required for PO Box 719, Centerville MA 02632 January 8, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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 solids or high stains present, liquid level even at all outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 "Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owners Name information is PO Box 719, Centerville MA 02632 January 8, 2008 required for ry every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: Four 500 galdrywells ❑ 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.): leaching chambers were found empty at time of inspectionwith a stain line 2-Y from bottom of structure indicating chambers have never had more than 2-3" of standing water. Soils are dry and sandy with no excessive vegetation. 08-03 Felegian.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owners Name information is required for PO Box 719, Centerville MA 02632 January 8, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): 08-03 Felegian.doc-08/06 ( Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 __ I 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is ry required for PO Box 719, Centerville MA 02632 January 8, 2008 -- every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference iandmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ♦ \ \ \ \ \ \ ♦ \ ' \ \ \ \l\ \ ♦ 4r\r\ \r\ \ \ \ \ \ \ \ \ \• . r f r \ \ \ ♦ 4 \ • \ \ ♦ ♦ \r 4r ♦ \ \!\ ♦F \ ♦ \ \ ♦ ♦ \r r J / i \ ♦ ♦ \ \ \ ♦ \ \ \�4 \ \ \ r\r\ \ \ \r\r\ \ 4 \ 33 18 ,\,.,\,\,.,♦,♦ Water Service . , . \ „ ♦ 23 40 31 s. 41 Stanley Way 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Stanley Way, Centerville MA 02632 Property Address John Felegian Owner Owner's Name information is PO Box 719, Centerville MA 02632 January required for 8, 2008 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 ground water: More than 20 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 15 and topo map shows property at or above el. 50. 08-03 Felegian.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �pf 1HE 1p�� Regulatory Services snxxsrnBte Thomas F. Geiler, Director 9$ b 9 •0� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE LWATION SEWAGE # oZM1 'S� NTT-LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. q� SEPTIC TANK CAPACITY /YciG G L LEACHING FACILITY: (type) POO 441 e'1JeQ -J �y�(size) /J X % is NO.OF BEDROOMS BUILDER O WNE A 1- PERMITDATE: '-!G 'oS' COMPLIANCE DATE: if �3 USA Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Y Facilit 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 byner� 000 No. THE COMMONWEALTH OF MASSACHUSETTS FEE 1BOARb Of: HEALTH OF \� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade & Abandon ( ) - ❑Completes System ❑Individual Components ` tion L a Owner's Name � /a L�A ly MQ Ma /Parcel ddres Lot# Telephone# t�iA C.Cd9l�1 �tip+'� �'�-1 � 5�4s(.y1oF,yfNlr st /�EAv`� ezJCfi Installer's Name Designer's Name t. Address AA tw Sb —f7 6Address LU Telephone# Telephone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flowd_lo(o gpd Design flow provideOU6 gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) f1A41J Soil Evaluator Form No. Name of Soil Evaluator Date of 1Evaluation • DESCRIPTION OF REPAIRS OR ALTERATIONS— i.W&TAA - A— i&-tt6 �t — dol '3 — :CU 4 Qb 4 C €JU � 1 3 oc 4/—a V_ The undersigned agrees to install t above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to lac system in operation until a Certificate of Compliance has been issued/by the Board of Heal Signed to Ins e FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ss�s: No.X,Y?6 THE COMMONWEALTW61F MASSACHUSETTS FEE /00 B0AR'tf--0P -HEALTH '7b W 0 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair Upgrade AbandonE]Complete System E]Individual Components ki F 77"A ation f Owner's Name L"It" r p/Parcelf# dd,e Celji'7— Lot# Telephone# C✓4.,.34.4_L 41 Installer's Name Designer's Name 1 Address Address 'A%%lu Ak 6 L" Telephone# Telephone# Type of Building: 'S Lot Size /5 Sq.feet Dwelling No.of Bedrooms Garbage Grinder Other—Type of Building No.of persons Showers Cafeteria Other fixtures Design Flow(min.required) gpd Calculated dNign flow "(o gpd Design flow providedS D gpd Plan: Date Number of sheets Revision Date /J Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS— I N&*T-4AX- A- I T? C_ -1-AN)Vi- Ci k lo Cta rA&A-^,NA'ykj w S rZ N 2 2:W. The undersigned agrees to'install t e above described Individual Sewage Disposal System in accordance with the provisions of described in-per'. eal TITLE 5 and further agrees n0fi;yac the system in operation until a Certificate of Compliance has been issued by the Board of H Signed i*;' 1� ADate V/4 jw ,I V F /'AIt Ing, 'd -_ . V 1�z 61U U V FORM - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 --—---——————————————— ——---——————————————————————————————————————— -———— 7— No. THE COMMONWEALTH OF MASSACHUSETTS FEE -BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: E] Individual Component(s) E]Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired OF0,Upgraded(K),Abandoned( by: (3e A_-r-4"T n, L%)t-4 -T,--At4Cn1 14 4-.1 at C V't j PJ L" W^-1 has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow 550 (gpd) Installer Designer: Y �'Z'L'n'D o i T Inspecto> Date The issuance of this certificate shall not b�eicoqlstruecl as a guarantee that the system will function as designed. FORM 3 CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 ------------------------------------------------ NO. HE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct Repair Upgrade Abandon an individual sewage disposal system at *0 W A-qC t LA_k as described in the application for Disposal System Construction Permit No. dated Provided: Constr ct' n shall be completed within three years of the date of this p_ex"?�i't ondit10j'1§)jmust be met. Date Board of Hea'1th FORM 2,- DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W Homs&WARREN PUBLISHERS- BOSTON Town of Barnstable Rftutat®ry Services Thomss.F.Geier,jlreMr t public Bad*Dlvidon is Thous Nis�Gean,Dlreclor 200 Main Nreet,*AM"MA 02601 Faa� SOS•790.630° Of'�ce: 308-662•�i64�4 Date: �Vf�.' '6i�notaYters Z61oLA4 Dsden 3 Address: s.%�sjj,�(�� Address: �'J,J'��!/t ✓�>� D-2G 'I �v,,j1�.^�x� Baas Uouedl a Permit to inl 12L a on r C[ C septic eyete>no.at L � w based on a d0dP drawn by s ctr� !. �MAIdued q z 0 a y to /I earthy that the amdC syst m zefrszoaced ad a° o ®h as 1� I�llocatlon o the ' �istribuu dioon box md/a optic 4�h. ea i:e. thsott the •eptio em aferwood above WAS installed with major Sp t I cerdfy SAS m in Var""1000don of my . ion Component greater Haan 10 lstamll n�ordauca with Sato&Local Regulations. P'Ian of the septic or ®item)but folloar. cereed buslt by two OF ROGER PAUL MICF9NIEWI Z e� No.3042 IVIL 9 • x e Cr!! aw a �a e OF C-112AZELM Q:Hwlth/8opda/����esoe Cotton 1�0!'!11 Town of Barnstable P# Ile)O . oF� Department of Regulatory Services Public Health Division Date2 �-A) 200 Main Street,Hyannis MA 02601 n Date Scheduled Time 1 Fee Pd. /00 Soil Suitability Assessment for S e Dispo l J.Laden- �ct.0 la�,l - o R,S Performed By: witnessed By: b LOCATION&GENERAL INFORMATION Location Address (is 37RMLEI Wt4y Owner's Name 1,ew s Co C�rc7teJ'vaCl� Address 9Y 57)9,u4-EY KJRY Assessor's Map/Parcck Z Z6/1/.b Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Q...e.c la e.ul.k u.' Slopes M d 3 Surface Stones ' 6 e- D 5eV eA. Distances from: Open Water Body A ft Possible Wet Area Q ft Drinking Water Well NI Ar ft I Drainage Way Aft Property Line 15 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) t A, S (Jm� 13tl.tsla n.w Nh S � z y Depth to Bedrock 0 A- Depth material(geologic)�,LW'y- t BLGI�SQ_-.'�6�r�i' Depth to Groundwater. Standing Water in Hole: `` t�c ng-. Weeping from Pit FACe Estimated Seasonal High Groundwater 1254 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: 1* Depth Observed standing in obs.hole: in. Depth to soil mottics: C G ft. _ Depth to weeping from side of obs.hole: ::_- In, Groundwater Adjustment iG Index Well# Reading Date: Index Well level_: v._a Adj,factor_ Adj.Groundwater]level, n PERCOLATION TESL' bete ��� Tl= � Observation , Z Time at 9" Hole# Depth of Penc 3 7— 4 i- Time at 6" Start Pre-soak 11 @ ha Time(9"-6") End Pre-soak t � IR� I�N 1C� Vla t!J t Rate MinJlnch ^L'- Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conselrwation Division at least one(1)week prior to beginning. Q:SEPTICIPERCFORM.DOC I DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) O `1 C' V(tv to d-(O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.% 10 - 2,1" V- 0 C DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Flood Insurance Rate Mau: / Above 500 year flood boundary No_ Yes Within 500 year boundary No k Yes Within 100 year flood boundary No—::f/Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? _.,._._. Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envi nmental Protection and that the above analysis was performed by me consistent with the required training, pertise and experience described in�10 CMR 15.017. Signature - Date Q.\SEvn0PERCF0RM.DOC ' I DEs16N cArTEArA.• 6E/1 kRAL_ NOTES' DEs GN FL ow.• 1. 7HIS PLAN IS FOH THE DESIW AND TN1 S9T E!_E'r'.4 TIUNS.' BEIWOM DWELLING YJO 64L/LW Y PEA BET?oc V CONSTRUCTIO,"/ OF THF_ SF,YA SE IISf'CSAl. F 1!�bN Cii rD� FACILITY ONLY. IN✓FRT AT RIJI/_t'ING q7 •off INSTALL A SAS BAFFLE EQUALS V 0 GALS. PER QAY, IN OUTLET TEE, 0V'�R g.�•$. w0 (Imtvraf, GR+I�Q'!�•R 2. ALL CONSTRUCTION ,VETH00S• NA TF_RIAL S AND INV61IT IN A T SEPTIC TAAA' 0 �L 0161 .00 SEPTIC TANK REOUIREZt ,MAINTENANCE_ FOR THE SEPTIC SYSTEM SILJLL �- .if 0 ACCESS COVERS MUST BE ,YrTIlly CVNFCRM TO MASS. D. E. 0.E. TITLE 5 AND LOCAL lNYE<1T CUT AT . .PTl C Ti1 /h Ei 6 OF FI,V rSH GRADE. BOARD Ctc' HEAL TH REGULA TIONS. INVFAT IN A T D.ST. 1201 q _:,•00 _ 5�0 GPD X 200,r 0 0 6AL. I INVE-IT OUT AT VrS'T. 60X S•$d — '° 150 I' 3• VL s ET L OAOIN Ew mvoNsyrs NDEA suR IF- YST ETC.J INVERT IN A T S.,�.S. O �?�' 1 9 s� �Dn"'� °TIC TALC Pf�hOYIDEL2' 6AL. . �- J�ED STONE •5_4 SIZE OF LEACHING FACILITY REWIRED . 6H4LL BE DESISNEO TO XI TI-6TAND H-cV LOADING. B0 i7CH OF S.A. 3i a - 1/2 DIA. L IOUID I 2 . ASf 1FII STONE G S XINUTES/INal i 4. ALL SEXFA PIPE S V L L BE SCHEDULE 40 OR CBSFAVED SROUND,YA TER j DE10TH i �' DESIGN f'04C• RATE APPROVED EQUAL. AD✓l,�:'TED 6ROUh!i,i'A TE7 J 0 • + —=-�1 DIST. PROP 0 S.A.S. 6AL L OMS PER Lb4 Y 1500 GAL. BOX �•.»20 I 5. BEFORE STARTING CONSTRUCTION CALL DIG SAFE —� �- SEPTIC ANK ��'10) SIZE OF L&cHING FACILITY PROVIDE-a J-900-322-4344 FCR LOCATIaV OF r N-10 4- SOO GA-Li. C A G)" Co V-sG�. I U,;ID.=nGROU.�ID UTILITIES. NOTE.' I 6. DA TUN IS ASSY,,',Ea AW SEPTIC TANK 6 D-SOX TO BE SET ON A SIOEXAL L b S.F. X o 4 1 G 2 6PD 6' 909 OF CagPACTED CRUSHED STONE. BOTTOM S.F. X O•-14 4 40 4 6pD 7. NO DETE WMA TION HAS BEEN MADE AS TO COMPL LANCE CONP7w4 CTW TO XA TER TEST D-BOX TO WITH DEED RESTRICTIONS OR ZONING REGULATIONS. _WW LEVELNESS. TOTALS -] GG S.F. !G_ GPD I T SHALL. REMAIN TIE O,YNEl'S Rf-"Sf,ONSIBIL I T Y TO OBTAIN ALL REOUIRED PERVITS, SPECIAL PJdHITS, VARIANCES, ETC. FOR THIS PRO✓ECT. SOIL TEST PIT DATA B• IT SHALL REVAIN Thy' ONNER'S RES.PCWSIBIL_I TY � f�EYISl0/us' TO HA YE P YE PCPOSED DNEL L INS FO&UDA TICW T.P. -1 T.P. -2 /� Z.0 NO. LL1 TE REVISICW DESISMS9 TO ACCOUNT FGV Tf7' F_XISLAG OR,IDF_ ,GRA'D. ELEY, LOO. 00 6RVD. ELEY. 1�1 A1,D SOl L XNDI TICPIS AT THE L CCA i".,ro/1 CF 47.~ S.W. El.EV. G. ,V. EL E V. P��^PG:S� O,YEL L Ii lG. DATE' <i•1�•�� ! c C TEST BY.• JC l.A�-ab CJR'V Y�°JCS" L tVft . XrTNESSED BY,' '1pd1•y1M•D �7�i P1s �S PEAC. RATE 'Gr MIN./ IN. 1 C STR:AcA ,tk Or ROGICHNIEWCZ a ►OQ ,� . 'SION �� Q� ;�'" �� � � . +► -1i�'.. ;. ''T""" . .. � j ._,� �_ � fit! *��� ca a o ✓ .�- (V'Y,4 i }_ ...I "�tN OF li,� A �. i I. i `' RICHARD tiG ?4 r ' SF 0 F}, I I J Mqp oA I s F • � do n. � i�o la•d° o l LF ssz/. o'tia No.O3b031 N oe Spy V{�/ tl �M•,- �. 1 :i ( 1 I I �� Q 4 ,� <Fo�k� �< ,1 TCh, �+1�jkL' �A.` i a'1 . ..I .. ( F F /STE�� �a a I-77 zu T ` la 'O�ti 90 PLAN SHOWING A PROPOSED REPAIR TO AN EXISTING SUBSURFACE ,s..f,,•,� ,,a-ro�,R„ SEPTIC DISPOSAL SYSTEM Q 95 STANLEY WAY CENTERV I � • ILLE, MA. I i ���� C�p'Po � """_'�_ _ _. '4�pQ©S�•D �'��T�� SCALE 1"= 20' JUNE 9, 2005 fr..,)c��jl�l�..�G G�•S 3P ODLS �n�t� L �9L , puMo c�r�► Ago !,� F� ( CANAL LAND SURVEYING & PERMITTING FtiT i 'B��-'-��LL�-fl Y✓�-��► '�a To �4 y 306 OLD PL YMO UTH ROAD �.LtiMi�A•�. vb � �'3 . � SA GA MORE BEA CH, MA. PROJECT NUMBER 05-039 1 pLw>�, 3 0'