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:.-t PU' I NAM kUU1V'1 1. 0 ob-t 1-111 P•001 /001 F -508 ,.f.,..,DNAStQN,QF,.EWIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SM=1S005AL SYSTEM REPAIR
NO Internal Use Only
❑ i . In la �%In Watemhed
Repair PSI issued last W
V Rapair WW�86yds Cmw, W. BWch W Crotr Falls Res. Del ted
Repair vAR6 200 fL of a W'016rc=40 or DEC - mapped Wdarx! -Jointftview
SITE LOCATION
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at
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OWNERS NAME To+y) 0 LA PHONE
MAILING AD DRESS lu— C LO 4=
APPLICANT n -U
Name & ftatkmsbiFf.e.. owner, tenant, cannaa)
DATE FACILITY TYPE e PcHo comPLAINT #
PROPOSEDIN VALLER LS PHONE#
ADDRESS a REGISTRATION /LICENSE
)q( .90
p_ rom§g (incliide a separate sketch locating the house, pmparty lines, all adjacent wefts within 200
feet of repair acid the ImtIon of 9XIsting and proposed trenches)
NOTE., Repair most be in same fiocation'and of same type as original SMgO d!SP0SaI,$YsteM-
.-Dift, peAllowtion and proposed-pump systerns will requirq submittal of proposal from licensed proftssionai
engineer or registered 6roitii'
n A-N A In A -+-.0 `i An ^,, ,-,u,
as owner, or reported' ant owns ee e condificAs* stated on this form
SIGNATURE TITLE •01,v c- r"
i.
Procurement of any Town PeWit, if applicable.
Z , Subrwssbaof as Wit repair sketch in duplicate shovying;
a. "Ownv?s name
b. Site Street Name, Town and Tax Map number
c. Loostion of Installed components bed to two faced points
d. Systern description (e.g.. 1250 sal. Concrete sePtir., tank. etc.)
0. Installers' name and phone number
3. System repair be perfonro.d!
to accordance with ft
. mpoW and conditors.
Proposal Ap f ovsd '',,.Proposal Den
ied
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627
DATE I A eA7
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
-,D1-'%.-7IS10N.0FEN.V.-IRO ' NMENTAL.HEATLIT -SERVICES
FIELD ACTIVITY REPORT
WIFALVAI �.v C V
ADDRESS:,�41-� ZA 9A-ag! -
JZ5,0 AJ
Street Town State Zip
PERSON IN CHARGE
WGIM-12% 11 MRATA I MAI ff§]NWj
Name and Title
TYPE
• FACILITY:,
WAY
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Signature and Title
RFPn"RT,RF.CETvF.T) gy:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
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