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01308
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01308
Oct 11 11 02:00p Tyndall (845) 279-5989 P.1
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
THIS IS NOT A REPAIR PERMIT
PF OPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE �)
All informatior below must,be fully completed prior to any scheduling
SITE LOCATION 7 C e, TOWN TM #
OWNER'S NAME PHONE
MAILING ADDRESL
PROPOSED CON I RACTOR/INSTALLER PHONE # C/
ADDRESS C�0_ va gqREGIS T RATION ;LICENSE # &6-0
Reason for ex lor '"on:
❑ failure to surfs e ❑ back-up In house 0 find limits of syst6m for repair Cilother (explain below)
e- J- 4Q 102 A-ns
FOR COUNTY USE ONLY
1740:
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5si3ectoezWnatur4 &-Title i Date
intment Date: —Time:
kivexcetseptic
- Sheet 1 of _1
Putnam County Department of Health
Division of Environmental Health Services
Field Activity Report
Name: Gary Oakes Telephone: 278 -2827_
Address: _7 Parma place Putnam Lake , Town of Patterson
Street Town State Zip
Person in Charge or Interviewed:
Name and Title
Date: 10/ 15/ 11
Findings: Tyndall repaired baffle and 1 foot of pipe near tank from roots. No permit. Just
notification.
Inspector: e e- /9% Telephone:
Signature Ad Title
Report. Received by:
I acknowledge receipt of this report: Signature:
Title:
Field Activity Report. cw Date: