Work Notice Form (Page 2 of 2) in pdf

Work Notice Form Page 2

excavation in the street, and another at the shut-off valve. This work will interrupt your water supply for

about 4 hours, so we will notify you shortly before it happens so you can plan your water usage accordingly.

Because the portion of the lead service line you own can continue to affect water quality, and in fact,

partial replacement may actually temporarily increase lead levels, we urge you to replace your portion

at the same time. If you say YES below, we will authorize our contractor to replace your portion of the line

at the same time they are replacing the CITY/TOWN’s portion. We will provide you an estimate, and bill

you after the work is done. Most replacements cost between $XX and $XX.

Please fill out the bottom portion of this notice indicating your decision on replacing the portion of the lead

service line that you own, sign your name, date and return this form to us in the attached pre-stamped

envelope.

If you decide not to replace the portion of lead service line that you own, please be advised that potentially

the lead level coming out from your faucet may be elevated for a short time. Therefore, please make sure

that you use only fresh water from the main for drinking and cooking by flushing until the water after it is

cold, typically about 1-10 minutes depending on the length of the service line and internal plumbing. The

enclosed brochure contains additional information on the potential health risks of lead, and simple steps you

can take to reduce your exposure.

If you do not have your portion of the lead service replaced, we will need to enter your home within 3 days

of our work to obtain a water sample to test for lead levels. The result will be sent to you within 3 days of

our receiving the results.

Please contact us at __________if you have any questions. Thank you very much.

NAME

Town Manager/DPW Superintendent

________________________________________________________________________

RESPONSE FROM HOMEOWNER:

I have read this notice and agree:

• YES____I want to replace my portion of the lead service line for the estimated amount of

$__________.

• NO_____. I do not want to replace my portion of the lead service line, and I have read and

understand that lead levels may temporarily increase after the town removes the portion in the street.

Name:________________________________________Date______________________

Work Notice Form Page 2