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e ' CO.ORADO DEPARTMENT OF HEALTH
•t Water Pollution Control Division
4210 East lith Avenue
Denver, Colorado 80220
Owner:
i3c�ti�D � IJP of --,Plat es-4—
NOTIFICATION
s-L
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
e n 1) l'7 a ud A a k,
Mail Address: Bax /Ow I city /?1 Fit. 214/&5-6 Phone Gas -//SQ
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW:
Attach separate sheets or report showing entire area with respect to surrounding
areas, topography of area, habitable buildings, location of potable water wells,
soil percolation test holes, soil profiles in test holes.
1. Location of facility: County 6 ar Fie) d City or town fi, F 1 e
Legal description Lot size Jam' yc-re
2. No. of bedrooms 3 Septic tank capacity /Q G a Aeration unit capacity
3. Source of domestic water: Public (name):
weI1
Private: Well Depth Other Depth to first ground water table
ii. Is facility within boundaries of a city/town or sanitation district? Aft)
/<2.
5. Distance to nearest sewer system:
Have you attempted to arrange a connection with the system? /V&'
If rejected, what was the reason?
6. Rate of absorption In test holes shown on the location map, in minutes per ,inch
of drop in water level after holes have been soaked for 24 hours 2?
7. Name, address, and telephone of person who made soil absorption tests:
8. Name, address, and telephone of person responsible for design of the system:
7'7/
Date
Signe a of Owner
*Required by Article 66-28-12(CRS, 1963, 1967 Perm. Sum. Supp.)
**R.egc+Ired in areas which have been identified as areas in which danger of pollution
of waters of the State may occur (Art. 66-28-8{5), CRS) and/or areas in which there
Is no local septic tank ordinance.
B. SIGNATURES OF LOCAL OFFICIALS: The undersigned have reviewed the notification
described on the front of this sheet and recommend approval or disapproval of
the discharge as shown below:
Date Approval Disapproval
Comments:.
Signature for Local Health Department
Signature for City/Town Official (Title)
Signature for County Official (Title)
Signature and Title
Note: The Notifier (front of this sheet) must obtain comments and signature of at
least one of the above.
CFOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer:
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
WP -33(10-72-2)
.COLORADO DEPARTMENT OF HEALTH
Water Pollution Control Division
4210 East llth Avenue
Denver, Colorado 80220
APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
Applicant (Owner):
dv 19 I T1 City: RIFLE- phone:44,51),i4
c -Sea taiwv•AC •
Mail Address:
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW:
Attach separate sheets or report showing entire area with respect to surrounding
areas, topography of area, habitable buildings, location of potable water wells,
soil percolation test holes, soli profiles in test holes.
1. Location of Facility: County Q i(r Lb City or Town
Legal Description Lot Size: / >�
2. Type of area and facility - Number of persons served:
Subdivision Motel Restaurant Trailer Court
Other: PR W %; eltrO
3. Source of domestic water: Public (name):
Private: Well Depth Other Depth to first ground water table
4. Is facility within boundaries of City or Sanitation District:a
If so name:
5. Distance to nearest sewer system: 2 • sr
Have negotiations been attempted with owner to connect: 411 a
If rejected, give reason:
6. Rate of absorption in test holes in minutes p inch of dio� in water level iafter
holes have been soaked for 24 hours: iGiAt
7. Name, address and telephone erson who made soil absorption tests:
Qr. att ii."‘
8. Name, dress and telephone of person responsible for design of the system:
9. Est. bid opening date: Est. Completion Date: Est. Project Cost:
Date:
09,4
B. SIGNATURES FOR LOCAL GOVERNMENT OFFICIALS: The undersigned have reviewed the
proposal for the location of the above-described septic tank system and
RECOMMEND APPROVAL or DISAPPROVAL in the space provided below:
DATE APPROVAL DISAPPROVAL
Comments:
Signature for Local Health Department
r'
Signature for Mayor or City Manager
Signature for County Commissioners
Signature and Title
. Note: The applicant must obtain the comments and signature of at least one of the above.
C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer
Rd.
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
WP -10 (Rev. 5-70-100)