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HomeMy WebLinkAbout2902DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.15 -1 -17 BOX 24 Orr it: Ir oil a I� jr IL wl 02902 Q DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL pp� PCHD PERMIT #W _!U WELL LOCATION IS WELL SITE SUBJECT TO FLOODING? YES -----NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name A W d -14.„ Address: Q", IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: ✓ 5e00WA YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY -DISTANCE TO PROPERTY FROM' NEAREST 93"ER 11AIN2., LOCATION SKETCH & SO CES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: y2id l a, 19 C Date of Expiration 19 Permit Issuing Official _ Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller Street A'ddresg r own Village ity Z Z Tax Grid Number 1J'�_ I - $ - 1 Z WELL OWNER Name Mailing Address %(. � zZ Wlt, CR4-k SEe O Public USE OF WELL 1 - primary 2- secondary (RESIDENTIAL 0 PUBLIC SUPPLY 0 BUSINESS O FARM 0 INDUSTRIAL b INSTITUTIONAL O AIR /COND /HEAT PUMP O ABANDONED O TEST /OBSERVATION O OTHER (specify, O STAND -BY O AMOUNT OF USE YIELD SOUGHT OyU gpm /# PEOPLE SERVED Z /EST. OF DAILY USAGE gal REASON FOR DRILLING EPEPLACE EXISTING SUPPLY O TEST /OBSERVATION Q ADDITIONAL SUPPLY O NEW SUPPLY NEW DWELLING 13 DEEPEN EXISTIN WELL DETAILED REASON FOR 'DRILLING ' .lr A. ) t,t WELL TYPE LLED []DRIVEN []DUG GRAVEL ❑ OTHER IS WELL SITE SUBJECT TO FLOODING? YES -----NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name A W d -14.„ Address: Q", IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: ✓ 5e00WA YES NO NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY -DISTANCE TO PROPERTY FROM' NEAREST 93"ER 11AIN2., LOCATION SKETCH & SO CES OF CONTAMINATION PROVIDED SEPARATE SHEET (date) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a manner as not to degrade or otherwise contaminate surface or groundwater. Date of Issue: y2id l a, 19 C Date of Expiration 19 Permit Issuing Official _ Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller a PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL.HEALTH SERVICES' Date Re Property of K P_'J-- tom .Located at (T) Pc Section Bl o c k_2ji Lot^ Subdivision of IZ "`Subdv. Lot # Filed Map # Date Gentlemen: This letter is to authorize a duly licensed professional engineer or registered architect I (Indicate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County':, Department of Health, and to sign all necessary papers on my behalf in connection with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the.Putnam County Sani- tary Code. � k-'� , Countersigned: P . ; Y�-.A . , # �373G 27 Address 2 6 5- lf014g _Telephone Very truly Signed Tele )4 -6�L15 DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 N ._.. ,APPL;I(:A`1'1 `i;0 -�UN'S'1' tiTCT' `.A ` WATE�t WELL ' " __..._ . - ... _ . -..... . PCHD PERMIT # WELL LOCATION Street Address Town/Village/City Tax Grid Number o'er � t oC k _ J "T� WELL OWNER Name Em 1L lo Mailing Address \, N. )Wrivate 13 Public USE OF WELL 1 - primary 2- secondary )KRESIDENTIAL O BUSINESS O INDUSTRIAL OPUBLIC SUPPLY QAIR /COND /HEA UMP O FARM O TEST /OBSERVATION O INSTITUTIONAL O STAND -BY 0ABANDONED O OTHER (specify p AMOUNT OF USE YIELD SOUGHT ,L j , gal gpm /# PEOPLE SERVED /EST. OF DAILY USAGE REASON FOR DRILLING EW SUPPLY PROVIDE ADDITIONAL SUPPLY O TEST /OBSERVATION REPLACE EXISTING SUPPLY O DEEPEN EXISTING WELL DETAILED REASON FOR DRILLING J •-- 1 t V'.A_p 1f1lSs WELL TYPE DRILLED DRIVEN DDUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING? YES. , NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name My- aeAuc_ Address:, • -pu-m6 m IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: YES NO © 7- f AIM 1.0U 1)1� NAME OF PUBLIC WATER SUPPLY: TOWN /VIL /CITY b1 TANCE­ TO PROPERTY FROM NEAREST ­ RATER MAIN-:­­ LOCATION SKETQHA SOURCES OF CONTAMINATION PROVIDED N REAR OF THIS APPLICATION EPARATE SHEET t - L --R� „////)4 ? �n�� U Q (date) (s,7 gn ture) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit =a Well Completion Report on a form Provided by the Putnam County Health Department. Date of Issue: 19 Sy Date of Expiration: / 19 ermit.Issuing ffi 1 �6 White copy: H. D. File Permit is Non - Transferrable Yellow copy: Building Inspector Pink Copy: Owner 2/87 rlranrum mmr- Wcl l rri 1 1,=.r Z: . DEPARTMENT OF HEALTH Division of Environmental Health Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 ,0 'APPLYCATIUN TO CONSTRUCT,A WATEA WELL PCHD PERMIT # sir WELL LOCATION , S eetj Address Town/Village/City Tax Grid umber WELL OWNER Name < c < Mai in Address Private O Public USE OF WELL 1 - primary 2- secondary RESIDENTIAL 0 BUSINESS O INDUSTRIAL ❑ PUBLIC SUPPLY Q AIR /COND /HEAT PUMP O FARM p TEST /OBSERVATION O INSTITUTIONAL O STAND -BY D ABANDONED ❑ OTHER (specify O AMOUNT OF USE Y ELD SOUGHT s gpm /4i PEOPLE SERVED /EST. OF DAILY USAGE. gal REASON FOR DRILLING WEW SUPPLY O REPLACE EXISTING SUPPLY ROVIDE ADDITIONAL SUPPLY DEEPEN EXISTING WELL . O TEST /OBSERVATION DETAILED REASON FOR DRILLING Cx) otn e WELL TYPE f3DRILLED 11I7RIVEN ®DUG ® GRAVEL ® OTHER IS WELL SITE SUBJECT TO FLOODING? YES NO IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name ' a LS I h'r Address • Vk1! IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: _ _YES NO 16-&S ern a--)® I NAME OF PUBLIC WATER SUPPLY: litJ f wr)o 14b 15 _Z SOWN /VIL /CITY. DISTANCE TO PROPERTY 1ROM NEAAEST WATER MAIN: LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED 19QN REAR OF THIS APPLICATION []ON SE TE SHEET Lo X� - �z (date) (signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. Date of Issue: AvGya; aZ 19ss� Date of Expiration: � ;,,t '1 -'l.. 19 � a Permit Issuing fficial Permit is Non - Transferrable Mite copy: H. D. File Yellow copy: Building Inspector Pi 2/87 nk Copy: Owner (l r7-1 l r%-,* I I _ DEPARTMENT OF HEALTH Division of Environmental Health Services 110 OLD ROUTE SIX CENTER, CARMEL, N.Y. 10512 (914) 225 -0310 APPLICATION TO CONSTRUCT A WATER WELL PCHD PERMIT #- WELL LOCATION ,. S ree dress V lage City Ta Grid N ' b r. WELL OWN ame V1A_� fling Address e? S� , rivate O Public USE OF WELL 1 primary — secondary RESIDE IAL 0 BUSINESS 0 INDUSTRIAL 0 PUBLIC SUPPLY O AIR /CON /HEAT PUMP ❑ ABANDONED O FARM O TEST /O ERVATION O OTHER (specify ❑ INSTITUTIONAL O ST Q AMOUNT OF USE, YIELD SOUGHT gpm /# PF.OP�E VE / T. ,. REPLACE EXISTING PL TE T/ ERVA N O NEWS PLY NEW LL G N E IN WE L OF DAILY USAGE gal 12-ADDITIONAL SUPPLY REASON FOR DRILLING DETAILED REASON FOR DRILLING Moo I S.0 WELL TYPE WRI LED DRI N DUG GRAVEL OTHER IS WELL SITE SUBJECT TO FLOODING ?.? < YES No IF WELL IS LOCATED IN A REALTY SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Name A Address: IS PUBLIC WATER SUPPLY AVAILABLE TO SITE: _YES NO NAME OF PUBLIC WATER SUPPLY: ,o TOWN/VI L /CITY (f � LiJ LeaNr.s," -T3 'Pn6'1'ERT; --FnOY,' a1Eruno, yvni uit 1.1Ait1 - LOCATION SKETCH & SOURCES OF CONTAMINATION PROVIDED M ON SEPARATE SHEET (date) j A--.. signature) PERMIT TO CONSTRUCT A WATER WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State Sanitary Code, and provided that within thirt3� (30) days of the completion of water well construction, the applicant shall: 1. Pump the well until the water is clear. . 2. Disinfect the well in accordance with the requirements of the Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided by the Putnam County Health Department. During all well drilling operations, the applicant shall take appropriate action to assure that any and all water or waste products from such well drilling operations be contained on this property and in such a.manner as not to degrade or otherwise.contaminate surface or groundwater. Date of Issue: 19 Date of Expiration 19 Permit Issuing Official Permit is Non - Transferrable White copy: HD File Pink copy: Owner 3/89 Yellow copy: Bldg. Insp. Orange copy: Well Driller r' ry PETER C. ALEXANDERSON County Executive August 22, 1988 Public Health Director JOHN SIMMONS, M.D. Deputy Commissioner JOHN KARELL Jr., P.E. DEPARTMENT . OF HEALTH Director Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225-0310 Kent & Emily Zook 22 High. Street Putnam Valley, NY 10579 Dear Sir: Re: Well Permit # W -77 -87 Forwarded herewith is a permit to drill a well on the above captioned property for potable purposes. You will note that the permit is to drill the well only and is issued for one year. Approval to place the well in service will be granted upon receipt of the following: 1; Well Completion Report for. - .the—ne' w_wol.l 3. Information as to the depth of the old well. If you have any questions, please contact me at 225 - -0310, ext. 3Q4. V ry rul yours, am John Karell, Jr., P.E. Director, Environmental Health Services JK:cj DEPARTMENT OF HEALTH Division of Environmental Health 'Services TWO COUNTY CENTER - CARMEL, N.Y. 10512 (914) 225 -3641 _ A 3?LICA'I11 TO :CLiV J'1RUCT•..;.A_.. 1!YAt T\`YV�EL '; d� +3:r ,� . ✓+'k_ Wvi.Ur . «: PCHD PERMIT # WELL LOCATION Str et ddTress�'° Tbwn Village Ci ,y Tax a a� h S� Ve.e t iC��� V Grid -cNu ber ' V/ ° = %� WELL OWNER Name 3,,. Ma'�ling Addre s �C� +�T Euv�i 0 �` - 4 �� �rivate O Public USE OF WELL 1 - primary 2 - secondary 1-d"S DENTIA' a ,O PUBLICS 0 BUShNES.S,. _. O FARM i , 0 INDU TRIt>t�- -- [93NSTI-TU-T_ P� Y ) )&AI$ /COND /HEAT PUMP t O TEST /OBSERVATION L O_ STAND -BY 0 ABANDONED O OTHER (specify O AMOUNT OF USE YIEL OUGHT gpm /# PE (fLE SERVED /EST. OF DAILY USAGE gal REASON FOR DRILLING . •NEW:,: U PkYE I} O REP C. EXISTING SUPPLY OP OVIDE ADDITIONAL .SUPPLY O DE PEN EXISTING., WELL. OTEST /OBSERVATION DETAILED REASON FOR DRILLING f nc.>f�r �E_.. �, t,� it 'r Cr r rr �_ ,� ,cz D (A t U 0! L. Cc 6 '� y l WELL TYPE DRILL D DRIVEN DUG GRAVEL C1 OTHER IS WELt`SITE SUBJECT TO FL OD NG? YES NO IF WELL IS LOCATED IN A REAtT SUBDIVISION, NAME OF SUBDIVISION: Lot No. WATER WELL CONTRACTOR: Nam /�� ' S v dd ess : v � •S•PCe. S �� OiL IS PUBLIC WATER SUPPLY AVAI TO SITE:1 YES k` NO NAME OF PUBLIC WATER SUPPLY: u)ao t�h0 {c cSt TOWN /VIL /CITY��,i ha ran ,4 T - -.. •�DiSTAN1 CK- '•Tv "cR0 E:2TY ROii "D " 1-Fi«IATZR A11 : __.. _ �.. _ , LOCATION SKETCH & SOURCES OF CO TAMINATION, P OVI ED F::.. [TON REAR OF T IS PLICATI�N - -1� ON`A1tATE SHEET -'(date) ;_(signatu .e) PERMIT. _ M TO CONSTRUCT A WATER'WELL This permit to construct one water well as set forth above is granted under the provisions of Subpart 5 -2 of Part 5 of the New York State -Sanitary Code, and provided that within thirty (30) days of the completion of water well construction, the applicant s.hal l : 1. Pump the well until the water is clear. 2. Disinfect the well in accordance with the requirements of the.Putnam County Health Department attached to this permit. 3. Submit a Well Completion Report on a form provided•,by the Putnam County Health Department. Date of Issue: t,1`.` 19 Date of Expiration: + "'r = 'j� 19 ' Permit sluing Official Permit is Non - Transferrable White copy: H.D. File Yellow copy: Building Inspector Pink Copy: Owner 2/87 Orange copy: Well Driller PETER C. ALEXANDERSON County Executive Kent Zook 12 High Street Putnam Valley, NY 10579 Dear Mr. Zook: DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, Carmel, New York 10512 (914) 225 -0310 October 24, 1990 Re: Proposed well Zook - 48 -8 -1 and 41 -8 -12 High Street (T) Putnam Valley ff JOHN KARELL Jr., P.E., M.S. Public Health Director At your request, we have again reviewed your application to construct a water supply on the above mentioned parcel. Based on this review, the following was observed. 1. The existing well is located in the southwest corner of 41 -8 -1. a) The existing well is approximately 60' from the sewage disposal system on parcel #41 -1 -1. b): The, existing_ we %l o.i�s- :_12G_:fpir__.fronl. cur: se:wage::disocsl: system _anrt_:::<�_.: considered in direct line of drainage. 2. a) The proposed well is .reported 72' from the sewage disposal system on lot 41 -8 -11. b) The south east corner of 41 -8 -1 is 100' from all sewage disposal systems, except the reported system on lot 41 -1 -11. If your parcel did not have an existing individual water supply, and was served by a seasonal water supply only, neither site would be acceptable to this department. However, the existing well.is considered a pre- existing condition on this parcel. Therefore, the following will be considered by this Department. a) Redrilling and double casing the existing well, along with a letter from the well driller or professional engineer stating that the well and the water line can be adequately protected against frost. The large outcropping of rock between the existing well and the residence makes this a major concern. PETER C. ALEXANDERSON County Executive Kent Zook 22 High Street Putnam Valley, Dear Mr. Zook: r_1 DEPARTMENT OF HEALTH Division Of Environmental Health Services 110 Old Route Six Center, - Carmel, New York 10512 (914) 225 -0310 New York 10579 JOHN KARELL Jr., P.E., M.S. Public Health Director September 14, 1990 Re: Proposed well Zook 41 -8 -1 and 41 -8 -12 High Street (T) P V I have reviewed your application to construct a new well to convert your summer residence to a year round structure. The proposed well is in the. north east corner of your parcel and was found to be less than the 150 feet from two sewage disposal systems consisting of leaching pits. Therefore,... your.. application_ to. construct -a.. individual_ ,w.ater_ supply. - �in this locatiori' is denied: The survey indicates an existing well on your parcel in the south west corner. This supply can be reconditioned and placed in service, if you so desire. If you have any questions, please contact me at your convenience. Very truly yours, William Hedges Sr. Public Health Engineer WH /jp cc: BI (PV) b) Drilling .a new well in the southeast corner of lot #41 -8 -1 equal distance between the sewage disposal system on lot #41 -1 -11 and your own existing sewage disposal system. This location must be located by a professional engineer. If the new well site is chosen, the new well must also be double cased at least 20' into bedrock. Also the existing well must be permanently abandoned by filling with concrete, and a well abandonment permit and certification be submitted to this Department. If you have any questions, please contact me at your convenience. Very truly yours, William Hedges Public Health Sanitarian WH /JP cc: BI (T) Putnam Valley P(7--N'A-M C"-J-KITY HF-ALq ..14- DEPARMC-W DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Camnissioner of Health FIELD ACTIVITY REPORT - Sheet of NAME, 45;, 6; 1?e INSPECTION Orig. Routine ADDRESS 10 067 / - /? j Tbwn MAILING ADDRESS P.O. Box Post Office Zip Code TELEPHONE PERSON IN CHARGE OR INTERVIEWED Name and Title DATE TYPE FACILITY TIME ARRIVED TIME LEFT FINDINGS: C2 v Orig. Complain Orig. Request Campliance Canplaint Comp Final Group Illness Construction Reinspection Field, Sampling Only Field Conference Other Explain INSPECTOR: TELEPHONE: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: el DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Camaissioner of He2lth - FIELD ACTIVITY REPORT - Sheet of / INSPECTION NAME /-:F ( rte" � C Orig, Routine Orig, Ccanplain ADDRESS ,� , C °� �-z r /' Orig . Request No. Street Town No. �r �-� Canpliance —7 -- _ Ccanplaint Comp MAILING ADDRESS ` %. Final P.O. Box Post f ce --Zip Code Group Illness Construction TELEPHONE — Reinspection PERSON IN CHARGE Field, Sampling Only OR INTERVIEWED Field Conference Name and T tle _ Other DATE -' �° TYPE F ILITY TIME ARR606 TIME LEFT X Gj' Explain FINDINGS: .� .�•- ,, � to �.-� _ .. -__..... - '- Y��..� -'�•..^ -,.. �..:, /. �• ./y ,` �. ..%"cam^-' ' . -_`.;: r �� 1 ii6i'-,.%;G:% -. -. r� 4. -0`.; .. _.. .._ .- INSPECTOR: TELEPHONE: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE: PU TNAM Cr- -W-. I . HEALTH .: DERRUTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES John M. Simmons, M.D. Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of INSPECTION NAME �G �/ Orig. Routine �1 Orig. Canplain ADDRESS 2. lT r fir — <-� ° Orig. Request No. Street Town Compliance Canplaint Canp MAILING ADDRESS �-� .� f r��� g Final P.O. Box Post Office 1 Zip Code Group Illness Construction TELEPHONE PERSON IN CHARGE OR INTERVIEWED Name and Title DATE /�TYPE FACILITY TIME TIME LEFT r ,-a v, Reinspection Field,'Sampling Only Field Conference Other Explain �i� a INSPECTOR: Signature and Title PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report. SIGNATURE: 6/86 TITLE• TELEPHONE: Gum 03_ lb all d ® i rl rJ) . Q© vm _ , - l y �-, r7 tiUc��y ��,ti i ell r 11111AIC7 CIL � r 77 PUTNAM . C'QJWN, _ HF,ALTH _ DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Join' M. Simmons, M.D. Deputy Comnissioner of Health - FIELD ACTIVITY REPORT - Sheet ( of INSPECTION NAME e' % Orig. Routine _ Orig. Complain ADDRESS /i l �/ / % , Orig. Request No. Street Town TM No. _ Canpliance Complaint Camp MAILING ADDRESS Final P.O. Box Post Office Zip code Group Illness Construction _ Reinspection PERSON IN CHARGE Field, Sampling Only OR INTERVIEWED Field Conference Name and Title / Other DATE / ( X TYPE FACILITY TIME ARRIVED C �� TIME LEFT %) -> � Explain FINDINGS: INSPECTOR: r TELEPHONE: Signature and Ti e PERSON IN CHARGE OR INTERVIEWED: I acknowledge this Field Activity Report., SIGNATURE: 6/86 TITLE: FV Al N'07 /..t•/ .. Pil'I'NAEf COT?N'T'Y . LALTH- n ?AR`iw►F'h" DIVISION OF ENVIRONMENTAL HEALTH SERVICES Johni.m. Simmons, M.D. Deputy. Ccn4mi.ssioner of Health - FIELD ACTIVITY REPORT - Sheet of INSPECTION NP►i"ME_ 150 < _ Orig. Routine / Orig. Complain ADDRESS `Z 2 /��� <� T / Y �j/ - i'2 _ Orig. Request No. Street Town 'B1 No. MAILING ADDRESS P.O. Box Post Office Zip Code ,- TELEPHONE PERSON IN CHARGE OR INTERVIEWED Name and Title TYPE FACILITY TIME LEFT / 0,* V j Campliance Complaint Camp _ Final _ Group Illness Construction Reinspection Field, Sampling Only Field Conference /' Other W67, Explain INSPECTOR: f 14 = TELEPHONE: Signature and Ti e PERSON -IN CHARGE OR INTERVIEWED: :..3 ackhdwledge this Field Activity Report. SIGNATURE: 6/86 TITLE: _.,w,_ v `' � ��' S �'��� J i - �,.r h ..