HomeMy WebLinkAbout0120 VINEYARD ROAD - Health 120 VFnevard Road
Cotuit
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I Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is J
Owners Nary�e
required for every Cotuit MA 02635 2/24/21
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information Skit 151 g I
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East'Falmouth MA .02536
City/Town State ,'+ Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
2/24/21
Inspecto i na ure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•`; 120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The Septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Healt-i.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
f
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner Owner's Name
information is
required for every Cotuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
u 120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
El10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every COtuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
❑ ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
II — _
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Plan and permit on file fro 2002 for 6 bedroom system
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 710 gpd
9 ( Y 9 (gpd)):
Detail:
High reading presumably due to irrigation system
Sump pump? ❑ Yes ® No
Last date of occupancy: seasonalDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped 2013 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L— 120 Vineyard Rd.
Property Address
Hulbig
Owner Owner's Name
information is
required for every Cotuit MA 02635 2/24/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
cesspool
❑
Overflow cess P
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
2002 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
2'6"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well o >10'r suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
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II
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, inlet cover is under the walkway, outlet cover raised to 3"
of grade
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500g
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
>12"
Scum thickness trace
>2,
Distance from,top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
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.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-20 D-box is 3'6" below grade, cover raised to 12"of grade, no adverse conditions observed, use
caution when digging as there is an irrigation line over the cover
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
5
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Titre 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. CityrrowI State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leaching chambers were video inspected and are dry at this time, no indication of past hydraulic
failure, bottom of chambers is approximately 6' below grade, probing gives no indication of a raised
cover, chambers are H-20 per BOH record
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.;:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
l
Commonwealth of Massachusetts
,�-p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owners Name
required for every Cotuit MA 02635 2/24/21
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
6
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r%u, 120 Vineyard Rd.
Property Address
Hulbig
Owner Owner's Name
information is
required for every Cotuit MA 02635 2/24/21
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
(I�
ce —7�
1 �
6.
.l�
l �
I �
L-3
NZ),T TM ScNI G
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owner's Name
required for every Cotuit MA 02635 2/24/21
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: >125"
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: 2002 NGW 125",Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
4' seperation per 2002 compliance
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping shows the site at 20'msl and nearby surface water at 2'msl
Your must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�n ,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
120 Vineyard Rd.
Property Address
Hulbig
Owner information is Owners Name
required for every Cotuit ' MA 02635 2124/21
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information`.
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
i
t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
TOWN OF BARNSTABLE
LOCATION D ` �,'h e ago I'yI —
0
/cT SEWAGE #
j C �
ASSESSOR'S MAP&LOT
V LLAGE �14" Oaa
INSTALLER'S NAME&PHONE NO.,
SEPTIC TANK CAPACITY �
,X/3"X a
LEACHING FACILITY: (type) (size) r�®6
NO.OF BEDROOMS
_BUILDER OR WNE
PERMTTDATE: 10 C) COMPLIANCE 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
Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist. Feet
within 300 feet of leaching facility)
Furnished by
s.-
a a7'3 al C'
3 30
4
a
Ll.avr`Y�'3 /l S
F.
DATE:_4/27/02---------
PROPERTY , ADDRESS:_120-Vineyard Road ® � /
----- MAP �O
__-Cot_uit_Mass _
---------- PARCEL
LOT :
-----------------
On the above date, I Inspected the septic system at the abov- a i\iE®
This system consists of. the following:
1 - 1- Tunnel chambered tank . MAY 0 -3 2002
2 . Leaching. trenches
TOWN OF BARNSTABLE
HEALTH DEPT.
Based on my. Inspection, I certify the following conditions:.
3_._T.his,is_not a—title .f,i_v.e—septic system
(4 . The system is in failure ./1 FAILE® INSPE�TI®N
5-. -A- new-title- five- septic: system needs to be installed . '
SIGNATURE:,, - z—
Na me:_J _�._ Macomber �1r•,___-__
Company:_Joseph_P _ Macomber_& Son , Inc .
Box 66 A
Address : rlo
Centerville, Ma . 02632-0066
Phone:_ 508_775_3338____ �o
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & .SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed -
Town Sewer Connectlons
P.O. 'Box 66 Centerville, MA 02632.0066
775.3338 775-6412
•
COMMONWEALTH OFyMASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 120 Vineyard Road
otuit , ass.
Owner':; NameTeter Lu uer
Owner's Address; ox I T2 Hartlanaour Corners
Vermont 05049
Date of'ospcctIon;
Name of Inspector: (please print) Joseph P .Macomber Jr .
Company Name:J . P .Macomber & Son--r—nc .
Mailing Address:Box 66
Centerville , Mass . 02632
Telephone Number; 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, 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. 1 am a DEP
approvec system Inspector pursuant,to Section 15.340 of Title 5 (310 CMR 15.000). The system:
_ Passes
_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspectors Signature: Date:
The system inspector sha 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 grester, the inspector and the system owner shall submit the report to the app?opriate-regional office of the
DEP. Thc original should be sent to the system owner and copies sent to the buyer, ifapplicabie,•and the approving
authority.
Notes and Comments
-",,This only•describes conditions at the time of Inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use. --
Title 5 Inspection Form 6/I50-000 page I
Page 2 of 1 1 ,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION (continued)
Property Address: 120 Vineyard Road
Cotuit , ass .
Owner:Peter Luquer
Date of Inspection: 4 2 7 0 2
Inspection Summary: Check A,B,C,D or E/AL_ WAYS complete all of Section D
A. System Passes: d
4
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or-Ln--1 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
_ThhP - nrPSPnr Rpwaee system is in failure A new septic
cvctcm n.00rta to hP inatal1ar1
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.
,r
40 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibit's substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if,a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
JZ Observation of sewage,backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
! distribution box is leveled or replaced
ND explain:
1)6 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
i obstruction is removed
ND explain:
F
2
1 •
Page 3 of 1 1
OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) „
Property Address: 120 Vineyard Road
Cotuit , Mass,
Owner: Peter Lucluer
Date of Inspection: 4/2 7/0 2
C. Further Evaluation is Required by the Board of Health;
00 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:
/It Cesspool or privy is within 50 feet of a surface water
t2� 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:
1/0 The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of
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 ut 50 feet or more from a
private eater supple well'•. Method used to determine distance l�r.ULI
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no ot}er
failure crite6a are triggered. A copy of the analysis must be attached to'this form.
3. Other:
V0,46,
3
Page 4 of 1 1
OFFICIAL-INSPECTION FORM.- NOT FORVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4 PART A
CERTIFICATION (continued)
Property Address: 120 Vineyard -Road
otuit , ass ..
Owner-Peter Luquer
Date of Inspection: 4 27 02
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or"no" to each of the following for all inspections:
Yej N°
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 t .
.Static liquid leveLin t-he•dismbution-box above outlet invert due to*'
an overloaded or clogged SAS or
cesspool 1� �j, Ty- CA
iquid depth in c464f� of is less`Lhan 6"below invert or available volume is less than ''A day flow•
equired pumping more than 4 times in the last'year NOT due to clogged or obstructed pipe(s). Number
of times pumped �.
_ ty 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
/w ter supply.
y 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 Gom a private water
supply well with no acceptable water'qualiry analysis. ITbis system passes'.if the well water analysis,
performed at a DEP certified laboratory, for coliform.bacteria:and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia -
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.{
(Yes'No)The system fails. I'have determined that one or more of the above failure criteria exist as
described in 310 CM RR 15 303, therefore the system fails.'The system owner should contact the Board o
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must'indicate either"yes or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
des no
the system is within 400 feet of a surface drinking water supply h
V the system is'within 200 feet of a tributary to a surface drinking water supply
.the system is located in a nitrogen sensitive area(]interim Wellhead Protection Area- IWPA),or a mapped
Zone 11 of a public,water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owneror 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.
4
Page 5 of 1 I
i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 120 Vineyard Road "
otuit , ass .
Owner: Peter Luquer
Date of Inspection: 4 27 02
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 he 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<N/
Was the facility or dwelling inspected for signs of sewage back up?
1/ Was,the site inspected for signs of break out
Were all system components,*kluding 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 ? w
✓ _ Was,:he facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
_J/ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of>he failure criteria related Io Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J
. a
t
5
f
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Page 6 of 1 i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 120 Vineyard Road
Cotuit , Mass . .
OwnerPeter Luquer
Date of Inspection: 4 27 02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): _� — Number of bedrooms(actual):kh--
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):
Number of current residents: V_eLg6C sM6�wwl_
Does residence;have a garbage grinder(yes or no): 10
Is laundry on a"separate sewage system (yes or no):� (if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use. (yes or no): --
Water meter readings, if available (last 2 years usage(gpd)):LGy! u%4 ./' If we 11 has not been
Sump pump(yes or no): 4)0 e s t e d with in the past
Last date of occupancy: '�,yw r-G!1i' 'rtC1f J 12 months It should be
tested at this time .
COMMERCIAL/WDUSTRIAL See pages OA & 613
Type of establishment:Design flow flow(based on 310 CMR 15.203): 4V gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): je
Industrial waste holding tank present (yes or no): 4,,Y
Non-sanitary waste discharged to the Title 5 system (yes or no): _Ll)j,
Water meter readings, if available: �J,I
Last date of occupancy/use: 41q
OTHER(describe):
GENERAL INFORMATION
Pumping Records 1"1i
Source of in format ion:
isj/fJ/M,q ,
Was system pumped as pan of the inspection (yes or no):
IC yes, volume pumped'1 I) gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool
44 Overflow cesspool
'Ve Privy
. Shared system (yes or no)(if yes, attach previous inspection records, if any)
yD Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank 4/0 Attach a copy of the DEP approval
,�1e Other(describe): .1101e
Approximate a e , all components dat#stalled if known and source of information:
Were sewage odors detected when arriving at the site(yes or no): tid
6
Page 7 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION (continued)
Property Address: 120 Vineyard Road
7otuit , Mass .
Owner: Peter Luquer
Date of Inspection: 4 27 02
BUILDING SEWER(locate on site plan) -
Depth below grade:Materials of construction: cast iron 4Y40 PVC /other(explain): 7111Ae 1VW ,f6r
Distance from private Hater supply well or suction line: 1d e 49 T
Comments(on cond tion of joints, venting, evidence of leakage, etc.):
Joints appear tight - No av; rlanra of leakage The sysem
is vented through the house vents . .
SEPTIC TANK: Zlocate on site plan) / T,,)X
rr
Depth below grade: _
Material of construction: concrete4k) metal4b fiberglass polyethylene
tibother(explain) iti'11
If tank is metal list age:k is age confirmed by a Certificate of Compliance(yes or no):.(/J(attach a copy of
certificate)
Dimensions:/7 X oV X
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 6
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bottom of scum to bo m of outlet tee or baffle:
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels
as.related to outlet invert,evidence of Leakage, etc.); _
Once new system ; s installed Pump the septic tank every 2-3 �
years . Tunnel tank has no j n l P t t P P _ Has. witlet— tee_._Liquid—1 a v-e:l s
were above the inlet & outlet inverts . No evidence of leakage . This
is a 6—cham ered tank.
GREASE TRAP h;(locate on site plan)
Depth below grade: jg
Material of construction:.[J�concrete meta L4/9 fiberglass,_L_polyethylene_other
(explain): tiA
Dimensions: to
Scum thickness: t/
Distance from top of scum to top of outlet tee or baffle: �!
Distance from bottom of scum to bottom of outlet tee or baffle: 40
Date of last pumping: t)14
Comments(on pumping recommendations,'inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.): ,
Grease trap is not present
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART_C
SYSTEM INFORMATION(continued)
Property Address: 120 Vineyard Road
1otuit 'Mass .
Owner: Peter Euquer
Date of Inspection:
TIGHT or HOLDING TAN !1 �(tink must be pumped at time of inspection)(locate on site plan)
Depth below grade: VAi
Material of construction: -concrete metal Ofiberglass polyethylene,& other(ekplain):
Dimensions: .L _
Capacity: gallons
Design Flow: 11 gallons'day
Alarm present (yes or no):
Alarm level: .G' Alarm in working order(yes or no):
Date of last pumping: V,#
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present .
DISTRIBUTION BOX: Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:°
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.): `
nistrihntinn hnx ha.G• fnnr lateral ,, _There is- evidence of solids
carry over . No evidence of leakage into or out of the box .
PUMP CHAMBER42�d (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): .li%4
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):'. '
Pump chamber is n'ot present .
y
8
Paee 9 of 1 I
OFFICIAL INSPECTION FORM ---NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 120 Vineyard Road
otuit , Mass .
Owner: Peter Luquer
Date of lnspec.ion: 4 2 7 0 2
SOIL ABSORPTION SYSTEM (SAS): /(locate on site.plan, excavation not required)
Leaching trenches .
If SAS not located explain why:
Located : See page 10
Type `
4 leaching pits.•number: d
M,) leaching c:-tambers, number: Q
J,5 leaching galleries,number:
-A4 leaching trenches,number, length:
itlt leaching fields, number, dimensions:• Q
overflow cesspool, number:
!, innovative°altemative system Type/name of technology: hyzO, 1562)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): . -
Loamy sand to fine' sand . System is in h draulic failure . A
new septic system needs to be installed Soils are damp '
Vegetation is normal: Pumped at time of inspection . Sys'te_m was filled
duringg week end occupancy .
CESSPOOLSO. t/t,(cesspool must be pumped as part of inspection)(locate on•site plan)
Number and configuration: O
Depth-top of liquid to inlet invert: 4
Depth of solids layer: A! .,
Depth of scum laver: A14
Dimensions of cesspool:
Materials of construction:
Indication of gro mdwater inflow(yes or no): 2'
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present .
PRIVYV (locate on site plan)
Materials of construction: 144
Dimensions: X)14
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)`.
Privy is not
present-
• R
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properry Address:120 Vineyard Road
Cotuit Mass .
Owocr:Peter Luquer
Date or Inspcctioo; 27702
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch or the sewage disposal system including tics to et ]cast two permanent rererence landmarks or
ocnchmaiks. Locate all wells within 100 reel. Locatc where public water supply enters.the building.
XT��
1 v. cO
r 2h i
I
t 10
I
Page I I of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 120 Vinyard Road
Cotuit , Mass .
Owner: Peter Luguer
Date of Inspection: 4/2 7/0 2
SITE EXAM
Slope
Surface water - {
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:'
1 o Obtained fro.. tem design plans.on record If checked, date of design plan reviewed:
YCS Observed site(abutting prop bservation hole within 150 feet of SAS)
y— with local boardof Health-explain:
Y Checked with local excavators, installers- (attach documentation)
Accessed USES database-explain: T
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model 12/16/94 Ground water' elevations above sea level .
Used ; USGS Observation well data June 1992
Used ; Technical bulletin 92-000-1 Plat-P #2 _ Annual Ranges-of ground
water I e v P 40 of Croun
�f
Groundwater: �:-eel Below Bottom of,Pit High Groundwater,Adjustment*1,8 ft per Fnmpier Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is
feet.
y •nrnrw�n'rs�-'�— Trrrmr•ntnrrrnn rsnmrr.�+:�vnr�+r^s*rm mrtiv*�vrm+rrrn .���.�_. _. r,..
TOWN OF Barnstable WARD OF HEALTH
SUI)SVRFACF SEWAGF DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION I+
•••T•• �T••.••.•.—T.fl•.^�T.�1T.'IIt•I.TlITTTi'1/1•RTI"1`'^•.'1"1RTii1'R1Cr'I"ORR�1i�RT1p1R11R� AT •.+ar•T•r•�• .—. A
-TYPE OR PRINT CLEARLY-
PIIOPERTY INSPECTED
STREET ADDRESS 120 Vineyard Road Cotuit , Mass .
ASSESSORS MAP , BLOCK AND PARCEL # 016/022
OWNER' s NAME Peter Luquer
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P .Macomber Jr,.
COMPANY NAME J . P . Macomber & .Son Inc .r
COMPANY ADDRESS Box 66 Centerville , Mass . 02632
Strvvt Town or City State LIP
COMPANY TELEPHONE (508 ) 775 _ 3338 FAX ( 508 ) 790 - 1578
R .
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa7. system at
this address and that .the information reported is true ,' accurate , and
omplete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , 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 «hich I have conducted ha's not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 ; 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
i.his form .
_
' ✓/System-FAILED* �" \
r
The inspection which I have con -vcted- has found. that the. system -fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature Dat:
O( ne copy of this rt.ificati:on must be' provided to the OWNER, the BUYER
where applicable ) and the 130ARD OF HEALTH.
* If the inspection FAILED , the owner or*" "Perator shall upgrade ' tho system within one year ,of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CFIR 16 . 305 .
partd .doc
TOWN OF BARNSTABLE aj
LOCATION /;7 ��n e ue w✓-Gl I''ri�. SEWAGE # 0100"�
VILLAGE edr, ASSESSOR'S MAP& LOT P14- oaa
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) J .SO%ti/ (size)
NO.OF BEDROOMS 4
BUILDER OR OWNS
PERMUDATE: i(� * 0,2 COMPLIANCE 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
. y 0'
3
p� f. .
a o°
I
1
No. Fee
1 00.O
THE COMMONWEALTH OF MASSACHUSETT A Entered in computer:
Y
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zippfication for Diopooal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) i�TUomplete System ❑Individual Components
Location Address or Lot No. 1 ZO V1IVEYP►40 R4AD Owner's Name,Address and Tel.No.
COTvIT- WILt-IAM 4(301(6
Assessor's Map/Parcel 01l0-OL Z IZO VI YE M� Rom c omi IT
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.IV.
T C. lda C,y sv'f��7�� o�, SULLIVAN EV&INEERVJ6
3 3 y ��� s�'D�s .vl.��f .H,4 0���� 7 PP&KEK uAD)Yo.3o C. (oS9
-7 5 05TE&tus MA Sn&-4Z8 4
Type of Building:
Dwelling No.of Bedrooms CO Lot Size 1.3 taC9-P-5 sq, Garbage Grinder(A/4
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow G G-7 gallons per day. Calculated daily flow Ce(p(p gallons.
Plan Date OC-W"c I . ZOOZ Number of sheets Z„ Revision Date
Title QQOIaSEI> SmPQOy>cnetUZS
Size of Septic Tank .1500 &AQ Type of S.A.S. 5-600 (SAL (HNTA'BEkS IN
IZ•-10'x Sd-(o" F I ELp
Description of Soil O--!�' 0(.AYE�—[.oAINy� 3-9� /�L14NEQ- MED.SAAIj�
4-14' RI LAyER-FWE-*MED, SAuh, 14-34" 3Z Lmcgt MED_ skt-b
34-f*S" 0 LANERMjeD.S .1A/D , c16-2S"CZ FWE SA J — NO WKISK
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has beMiu and of alth.Signe DateApplication Approved byDate
Application Disapproved wing re,
Permit No. Date Issued1221
No.AQ!,
�41
Feelloo. O0
r " Entered in computer: A
- 44
THE COMMONWEALTH OF MASSACHUSETT ..- p
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,.MASSACHUSETTS Y
.r--
. rication$for �Diopooal *pztem touotruction Permit
Application for a Permit to Construct( . )Repair Upgrade(V)Abandon( ) Rtomplete System ❑Individual Components
Location Address or Lot No. I Z,Q VINEYAt� 'kCkb Owner's Name,Address and Tel.No.
COTS IT`
Assessor's Map/Parcel "J f
ol a
io-OZeu Ito VI :'YA o ti �eVI-r
Installer'Ts Na/me,Address,and Tel.No. Designer s Name;Add/ress'andyTepl.r�o.
V•'^ �/ l/f7 �,py Syidt�r'0� SuL WVAN ENt�I NEER�N� -
r _ 7 MKE K Roth,?-0Z0x (6 5
( o r) v.7k s E v 506-4Z8-1344-1
Type of Building:
{ Dwelling No.of Bedrooms (D Lot Size 1.3 ACRES -sa—& Garbage Grinder(A/q
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
r
Design Flow/ (77 gallons per day. Calculated daily flow Co(ay gallons.
Plan Date OC�a1�e- 1 . ZOO Z Number of sheets Revision Date
f -Title I�(�t"'a5E 17 ZMN0QerAEVTS
" Size of Septic Tank ISO . (64L Type of S.A.S. 5'SQ0 &AL ("myeegs IN
IZ'-IA° x SO-(," FIEBLD ._
Description of Soil O-'S 0 LA%/6k- LOAMN, 3-i A L Al1E N1ED.sANrj
9-14` Bt LA-4E9-FWE-1,M6 . Skuh. 14�`:3N' 6Z LA'il= ' M6D. �,AN*b
i
34-6S" C 1 L.A\IC- Mrch.SA03 . GS-IZS VL FWtr .SAA/b -- NO WA"TGR,
,k Nature of Repairs or Alterations(Answer when applicable)t
A
Date last inspected: l
Agreement:
E 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 beNsu is Board of ealth.
Signe F Date 7'a
Application Approved by Date `
Application Disapproved for e following reaso?s V
Permit No. Date Issued
----- ------------------ --- -- ——————— -
THE COMMONWEALTH OF MASSACHUSETTS 1
BARNSTABLE, MASSACHUSETTS °
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site'Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by
m�
at 20 u i has constructed in accordance
with the provisions of Atle 5 and the for Disposal System Construction Permit No �_ ated
Installer Designer
The issuance of Vs pe it shall not be construed.as a guarantee that the system i da d°s*gne
Date 2 L 4 Inspector 1
----------------------Fee HOC) UO
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1
Digo.5af *p,5tem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
Systemlocatedat 120 YINEYA2ID, ROAN (UTUM
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.
Provided: Construction must betmpl t within hree years of the date of this pe t
Date: 10 -5 O x- A roved b i
__a_�__ PP Y l
— --- F ---- - ----
No. - - - ee --- -- ------
BOARD OF HEALTH
TOWN OF BARNSTAB LE
zpptication for Melt Con5truct ion Permit
Application is hereby made fora permit to Construct ( ), Alter ( ), or Repair (VI<n individual Well at:
A ocation — s�� — —Assessors Map and Parce--------------------------------------
ks Ad l
- ----------------------- ! t
ner Address
billl-t f ---------
Installer — Driller ddress
Type of Building
Dwelling --
- Type of Building ---------- No. of Persons------------------------------------------------
Type of Well-- - - - -- ---------------- Capacity-- - - - --
Purpose of Well - ---°}"--
d,rt.N1ZIIn� UXLJ- '.
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed- - -—- -- ---------...........
— - '- -----------/daie----
Application Approved By--
ate
Application Disapproved for the following reasons:-------------------------------------------------------------------------------------------------------------
— - - ------------ --------—-- — -- —- -- ---------------------------------------------------------------------------
J � date
PermitNo.--------- ------ ----------------- --------------------------- Issued-----------------------------------------
date
BOARD OF HEALTH
TOWN[ OF BARNSTAB LE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual.Well Constructed ( ), Altered ( ), or Repaired (✓f
by----- r �------ - --
Installer
at- ��-�� } - -
has been installed in acco ance with the provisions of the Town of Barnstable Boa o Health Private Well P o x
Regulation as described in the application for Well Construction Permit No. -�-Dated-�19 -- �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------—------------------------------------------------- Inspector----------------------------------------------------------------------------------
If
No. - Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZlppYltatlon_*r3VeYY Con!5truct ion Permit
Application�Iftu
hereby made,fDr a permit-to ConstFuct ( ), Alter ( ), or Repair (�n individual Well at:
1 ab cy
? tioncaiTC — A dress Assessors Map and Parcel
r
r Address
�'1 ee.hc�.rti �r►ll►r�ur----- 3�$ -z___-�_.�__. __�__o_,��..�,d�«h t w�14 aa.��3
Installers— Driller 0 —^ Address
Type of Building -
Dwelling r V G � o W �• —
Other - Type of Building No. of Persons---________________—______—__
Type of Well- -�-- -- = ---- ---- Capacity- ---- _--- ----- ----__ —
`'Purpose of Well _D rOUi E' �
__ - OGBe�_ -I�__
Agreement: .
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed' ----------- �'�: -- -- — -- ------- --_—---
Application.Approved By-----_--------__---- ______--_----------_-_ -- _%_�—__v
date
Application Disapproved for the following reasons:------------- ------------------ --- ---- --
/„ /r date
( ,// �
Permit No.----------- .------- /fJ Issued----------------____ ________
date
o-
BOARD OF HEALTH_,
TOWN xOF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual.Well Constructed ( ), Altered ( ), or Repaired (�
Meeh0X' W-01 JaD 1 I)no,,,) -------------------------—--------------- —--- _----- -
V'. � �, Installer
i ao _ __
at---- - - - — -1---------- ----- -—_-_ —__— - - ------ -----------
has been installed in accordance with the provisions of the Town of Barnstable Boar of Health-Private rivate Well P o:te tion,�
Regulation as described in the application for Well Construction Permit No. ----:-------------Dated---=1-.-----;--------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------ Inspector---------- -------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
�. erY �or� tructiort Permit. h.
W ~ Fee— /- ---No. -- --:- �;-�--- -
Permission is hereby granted YY��Zu C�► ' W ' � 1�11 )1�G _- ------------- — ---
to Construct Alter ( ), or Re air ) an Individual Well at:No. U
a
YLtvUX' _--
Street
as shownn on�th appl'cation'for a Well Construction Permit
W
Cf
No.---- - - -- ----- --- Dated__ - _a AA —�-- --- -- C
( � ( � � � -------------�---------------Board.of Health'.— ---
-------------------
DATE-------------�------------------------:---------------------------------
.�1?T(iTTT(t'i'TrTt??T?!TTTiT?TtT?(TTIti?tltir)?rrTPtTJrr???T?fs,J�Tt??ilnT?prtr?ntiftrin�frrr?tttTrtriniJtr,TprJirr?nrfffifntTt,nmft,t?*+,rillnttt:,nt�Tr nT Tn !I!, rr rirr nrftxt tt�'rru tm rnt
1 ..........T..T.,i...
.t?T t. ,1... ...,...titTi.,TL,tittTTiTn;,,
=_ ENVIROTECH LABORATORIES
Mass. Cert. #:MAO63
449 Route 130 Sandwich,MA 0.2563 (508) 888-6460
CLIENT: Peter Luquer LOCATION: 120 Vineyard Rd.
206 cu artown Rd.
ADDRESS: g Cotuit
Devor_, PA 19333
== COLLECTED BY: Meehan Well. Drilling :SAMPLE DATE: , 10-17.-91 y TyiME: 1:30
;:.
10-17= 1
DATER 9 ' ET801
RECEIVED: SAMPLE'ID:
JOB p: Existing Well Repair _ WELL DEPTH:
RESULTS OF ANALYSIS: �y
_..
Parameter Units Recommended limit Result4 =
Coliform bacteria/100 ml (MF Method) ;. 0'
0 "
PH PH "units. = -- 6:0 8 5 . 5.37
S
c Conductance umhos/cm -
__- 1 ._
- 05
Sodium mg/L. � f '' 20 0
` 13:3 i
Nitrate-N mg/L 10`0 -
<0.03
mg/L "0.3'
BE: Iron
0.09
Manganese mg/
L' 0.05 -
Hardness mg/L as CaCO 500
3 ;
c: Sulfate _ , mgi L 250'
Potassium' mg/L - - 20:0
Alkalinity mg/L
>w: Chloride mg/L " ' 250'
Turbidity .NTU 5.0
Color- APC,units t 15:0'
Background bacteria'
COMMENT:
Low pH indicates high':corrosive characteristics.
J
E:
YES No WATER IS SUITABLE FOR DRINKING PURPOSES'FOR PARAMETERS TESTED. -
RX;
DATE
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-9 REVISION DESCRIPTION
:� ., ■
I�
.. .
IFLOOR PLANS
4„ B
J7 1 L
Ouse
m
Garage o LC -
If 1st Floor Bdrm 25'-6'
O TV Room
-- ------------------------------ I� Closet
B 4.
4'
❑ ❑ II
2
20-10 j 4 Great Room
32'-6 44'-10•
�, Dining Room j .�, 34'-0
25'-7-
Oueen
o � o
Dining Room
Back 2nd Floor Bdrm 4 - III
13'-9' I 14
18-4• '
:0'0" '. C`uean Guest Bdrrr' I 0 11
I ,2'-0'
6 I'
TV
20 LC LC
iW l
_I Bath E�-
2" Balth"�III ❑ 4'-0ro -8
__'Bath 8�U (__) O I 1; 1er f oO 11916'F' 1 S 4'_7..3'-6•- 3'-6' Bathi - 5'-0'3'-6"12'-0' 11-0 3'-10` ._11.>,4-2 ---------Kitchen
6Eating AreBack Hall(Open Ceiling) I 'O41 �j - ,,:c 4-0" ' 4• 5•-0" .
I ^1•It
O
LC Bath 1 8 ....
(777777777)
O een� {ri 14'-0'
.,' I Sun Room - ..
1 12'-0` 22'-4' 1 T-0" 16'-6"
I I
I Front Bdrm 20 1 I - I :L 26'-5`
I Closet I e I -
I O een- Master Bdrr '
I
I
Closet I 26-0"
•—.T-0" 9'�' .. 6 Scale 1/4'=V-0•
" Kitchen
Foyer
1.
1 ( Lott -
El
i!--I- - 12'-0"
13-0. I .
i
i
i
i
j
Floor Plans _
0
�
Fimsh Cimde TEST HOLE - 1NOTES
, I
- 09/30/02 EL. 22 1. Water Supply For This Lot is Municipal Water.
3'Vex _.,_ - . . ..-:-r:_.. � �. �.'_�:;�;:__. Filter
9"Mitt .. _ -�-._� -. ,.� ... ,,
Compacted Fill _ _ Fabric O LAYER lOYR 3/3
2. Location of Utilities Shown on This Plan Are Approx.
DARK BROWN
_ R �r t .x At Least 72 Hours Prior to Any Excavation For This
2`
„8"_1„" 3 LOAMY 21.75 Project the Contractor Shall Make the Required
Pea stone A LAYER IOYR 5/3
GRAYISH BROWN Notification to Dig Safe (1-888-344-7233)
91'' MED. SAND 21.25 3. The Contractor is Required to Secure Appropriate
3' f B 1 LAYER IOYR 4/4 Permits From Town Agencies For Construction
1 DARK YELLOWISH BROWN Defined by This Plan.
LEACHING
CHAMBER 14;" FINE-MED.SAND 20.83 4. Install Risers to Within 12" of
! 3/4"-1 v2" tp B2 LAYER 10YR 4/6
H-20 Double washed k Finished Grade.
1ad
e.
s t Scene DARK YELLOWISH BROWN 5. All Structures Buried Four Feet or More or Subject
---------= `, -:.---- 341' MED. SAND 19.71
— C 1 LAYER 2.5Y 6/6 to Vehicular Traffic to be H-20 Loading.
OLIVE YELLOW 6. Septic System to be Installed in Accordance With
-
310 CMR 15.00 Latest Revision and the Town of
12 l0" 65" MED. SAND 16.58
C2 LAYER 2.5Y 6/4 Barnstable Board of Health Regulations.
CROSS SECTION OF CHAMBER LIGHT YELLOWISH BROWN 7. All Piping to be Sch. 40 PVC.
NOT TO SCALE 1Z� FINE SAND 11.58
NO GROUNDWATER ENCOUNTERED
APPROX.GROUNTWATER @ EL.2.5
VENT
Design Data
F.G.EL.19.5 F.G.EL.20.0 Single Family- 6 Bedroom
See Note a(typ.) With NO Garbage Grinder
Daily Flow= 110 x 6=660 GPD
L.19.0 Septic Tank: 660 GPD x 200%= 1320 GPD
Use 1500 Gallon H-20 Septic Tank
s 1500 Gallon s s i
Se tic Tank Leaching Area
p
H-20 Flow Eq Y l L 660 GPD/0.74= 892 SF Required
uilizers ;
As Required EL.1 l�
Y 3' Sidewall=2(12'-10" +50'-6")2 =253 SF
-
t Bottom Area= IT-10" x 50'-6" 648 SF
1 .r - —r--- ------� Bot.El.15.2
Bedding&^T^s 901 SF Total Provided
nF '. as Per Title 5 If Encountered Remove&Replace
h— n ,�,, t All Unsuitable Soils Within 5'of F Chan-
PETER -�KIM i TheOute,PermeterofTheSystem `' Leaching Chan-i er .I ESF8-n
S � ��_ !
00•29733 Groundwater EL 2.5
co DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM All Pipes to be Schedule 40. Use
��
NOT TO SCALE PerT.o.B.Map 5-500 Gal. Leaching Chambers in a
IT-10" x 50'-6"Washed Stone Field as
Shown.
Title: Prepared B Prepared For: 1n
Proposed Improvements P v P Date: October 1,2002
At Sullivan Engineering,Inc. CapeSUry William Hulbig
PO Box 659 7 Parker Rood 120 Vineyard Road Scale: As Noted 2-
120 Vinyard Road
Osterville, MA 02655 Osterville MA 02655 COtult, MA 02635
Barnstable(Osterville), MASS. (508)428-3344 (508)428-3115 fax (5)8)420-3994 (508)420-3995 fax project A 22033
PSu11PE@dcLcom l capesurvOcapecod.net N
,..,1 .w. µvi. • 1)t,•r.•'0 .tip`'/
Y74-
Flood Zone Lines From FIRM Mop ASSESSORS REF
Community-Panel No. 250001 0022D
�MapRevised: July 2, 1992
1 Map 16, Parcel 22
unity
Pde V Ol '
_ 100 rz. OVERLAY DISTRICT: r rT . ��.
Top of CB/dh Fnd c c ;
. L cue
Elevation = 20.06'(NGVD '29)
T
.berry J ! � 0
AP - Aquifer Protection District "d
1 I a ilo�—I ,�
_—q0 _ 0 �,� ro ^ h a , unkX •rd .d
As Shown on Plan Entitled .• o
20
l , / / ) 1 I ..
cB/dh r-- ,_ �9000'oo'w l / I Revised Groundwater Protection
kno
375.00' Overlay Districts" - April, 1993
Lot 15A
/ Setback
LA-
Mea d-- -- -- -N --
39.2' 40.7( 0-0
sn FLOOD ZONE: rk
WoodFence
3 I
Zone C, V11 & V17
iW i / I I 1 b Cellar \ \\ \ I I Island
I I Community Panel No.
Q
I :' I I 1 Entry \\ \ / \ I ` / / I 250001 0022 D s
so,e Jul ,
�'
2 1992
LOCATION MAP:
1 0 ° c - First Floor
61.8' . °o°tea I I Wood foe a El.=20.8' ' / / 1
I / I /' f /' /' Scale 1" = 2000'
ko
I unkiry 2 Star
Wood FromDwelling,
Dwelling Directions: From H -
I o I / z— �� 12o Hyannis Follow Route 28
o I j / // �/ I /I I % / ////// /� a .' y
2 / I / / I ! / / towards Cotuit• Take a left onto Putnam Avenue _
Take a .left onto Main ZONE
' 1 / and follow to the end
` � •
I ' Lot 15 / r`� '/ 4 ' i 1 I l/ l I I 'I l mi / / ,� Street; At the end of Main Street continue
I 1 I 1
� J G / . straight onto Vineyard Road; House is on the
/' ,� j/ �� I / // / // //' / left, #120. Area (min.) 43,560 SF
�� �/' ;' --- �/ ,,� f /l \ l // /"/� ,/ Frontage (min) 150'
/ ; // %l l I l �/ Setbacks:
o1, ------------=--==-=-----=--r=--�---=_----= - --,'- -- -/- -- Front 30'
> ti ........... / /
Gravel Driveway \
-----r---- _--''' , tree LMe / �+
----- " ---------- ---4- ----- , % I l I 1 l /' / // V Side 15''
/ /' �' I• lFnd
l l // Rear 1
I I 1 / l l l
W i Top of I
Coastal Bank
' rn
1 C<.i.114163
I a /11 H
1 I �41
CB/dh CB/dh bgO o
Fnd umty Fnd
Pde
Exis tin1 -j n ditio n s
Flood Zone Lines From FIRM Mop
Community-Panel No. 250001 0022D
Mop Revised: 4uly 2, 1-092
p'
UNIty
..gym . Nlr
P01.
' Pde Connor
!t.1094 Pg.51 100 Year Flood Elev. = 14'
Top of CB/dh Fnd
Elevation = 2C.06'(NGVD '29)
Ii ZO __ N �' /0 •,'1 'pro 'b M N CO
I -"'0O0'00"W
1 , CB/dn i 375.00' ..ram
I I Fnd �- i I / I / / 1 Cb%dh 14 f l I 1 I I 1 1 t
Lot 15A ' 1 ,' / /' , Fnd
O I e�Mh9 srroock Lk.._ l D�
i I„ -•---- -- -- -- --"-- - - - -- - -I- -- 7 --/-- --• -i-•— won •-- --•-�- --.r-�. /f -f- I I � \ \
I I N I ( Exls ing Septic e
(To Be Abandoned)
/ �/ •'� l / I J
'W o Proposed 1 roposed Addition B�ck Patio \�
I
1 I './ Paved 1 (typ•) \ / \ \ l' I 1 I •;. 1
1 I Ao I , O Drive
1 , O i • Catch Basinl& 1 -I = \
1000 Gal Leaching I I �0 :�
Buffer Pit w/2' of IS tone -a,,
for DrivewayIRunof Ex/jing Founda
To Remaintion / - l ' /*
leEx ng Well Work Limit DouStaked
10' eBe
/Used For \ Hayboles wl Silt Fenc•ng
Min Only)
�rrl otlon �• /
nP'dely I / 1 9 y)
`U I 1 I a o0 1 -160C Gal Drywell w/1' of / 22-/ / Ma O / by / I l I l /
0 i i 1 O Storle for Roof Runoff(typ. O / O
Proposed Septic ystem
1 I / (See Sheet of 2)
1I I Lot 15 TH_1 // \ // / Proposed Addition ; 1 r. i �/ JI I / // / // // /ti O
20
i 1 --- -- — — , i-
Tree LMe
i l' lFnd
9000'00',E/
/ A
i Top of Il /
N/F c o Coastal Bank
1 f Oi Lloyd
Cert.114163 �• b I 1/ l
- b
1 1 I 41
bpk'
I 1
CB/dh CB/dh
Fnd uiity Fnd
Pd.
Proposed "provments
R
SIKL IVAK
29738
CIVIL y
Title: Site Plan PREPARED BY. PREPARED FOR:
Notesl Revision:
Proposed Improvements SUIIIVaII En 1neel"lI1 Inl,. CapeSury 1.) The property line information shown wo'3g g1 William Hulbig
At PO Box 659 7 Parker Road compiled from available record information.
120 Vine and Road
-/ Q Osterville, MA 02655 Osterville MA 02655 y 2.) The topographic information was obtained
1 2O Vin�i,yard Road (508)428-3344 (508)428-3115 fox (508) 420-3994 (508) 420-3995 fax CO tUl t, Mo. 02635 from an on the ground survey performed on
PSullPE@ool.com copesurv@copecod.n e t
Barnstable, (Cotuit, Mass. 9/AUG/02. o
Draft: JOD Field: WHK MDH 3.) The datum used is NGVD '29, a fixed mean
30 0 15 30 60 120
Date: Review: PS Comp.: MDH sea level datum.
October 1, 2002 p.:
Pro'ec t 22033
.,,... . - ,..,.. ., ,.,,_._ . - - J #� Drawing # C473_2G1.dwg