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.QLQRADO DEPARTMENT OF HEALTH
Weter Pollution Control Division
_ 4210 East l l th Avenue
Denver, Colorado 80220
Bu,i 1ding Offics<ral
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Owner! j'4 l ,e//J 'ere
Ma I 1 Add res s :7 7 % ) (J 4/45/ Ci tyG'erA/ly+ E0-1/ I p y/%af Phone 95./7-.970-57,
A. IWFCRMATION 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,
soli percolation test holes, soil profiles In test holes.
1. Location of facility: County (700.4!"-/4.7449 •City or town 9—Lexi werdoa
Legal descriptionsligileALLot size /3
2. No. of bedrooms Septic tank capacity/25a Aeration unit capacity________
3. Source of domestic water: Public (name): A7/7-01/0.4_ cif E/Z c.�9TE5Ccvripo.
Private: Well Depth Other Depth to first ground water table
4. Is facility within boundaries of a city/town or sanitation district? /U
5. Distance to nearest sewer system: /4'1/
Have you attempted to arrange a connection with the system? N c3
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
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:__
lq :amu /
a242,-(1-1 — /97Y
Date
Signature of Owner
*Required by Article 66-28-12(CRS, 1963, 1967 Perm. Sum. Supp.)
**Required 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
Comments:
Approval Disapproval
d
Signature for Local Health Department
Signature for City/Town Official CI i tie)
Signature for County Official (Title)
Signature and Title
Note: The Notifier (front of thissheet) must obtain comments and signature of at
least one of the above.
C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer:
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
WP -33 (1 O••72_-2)
r
All that part of Lot 1 and that part of the NE4SE4 Section 5, 'fp. 6 S., R. 89 W., 6th P.M.
described as follows: Beginning at a point marked by a cross on a flat rock on the East
edge of a mesa, West of Oasis Creek whence the Southeast corner of Section 35, Tp. 5 S., R.
89 W., (said corner being the First Correction line South) bears N. 45°37' E. 2225.97 feet;
thence along and near the Easterly edge of said Mesa S. 21°43' W. 124.58 feet;
thence South 84°06' W. 368.69 feet to a point on the Westerly line of said NESSE-;
thence North 2°02' E. 669.60 feet along the Westerly line of said NE,—,SEu to the Northwest
corner of said NESE-, being the SW corner of said Lot 1;
thence S. 88°06' E. 242.30 feet along said line between said NE4SE* and said Lot 1;
thence N. 14°45' E. 397.54 feet;
thence S. 66°22' E. 430.52 feet to a point on the Easterly boundary of said property;
thence S. 29°32' W. 177.10 feet along and near the Easterly edge of said Mesa to a point
marked by a cross on a flat rock;
thence S. 16°44' W. 135.60 feet along and near the Easterly edge of said Mesa to a point
marked by a cross on a flat rock;
thence S. 30°58' W. 165.10 feet along and near the Easterly edge of said Mesa to a point
marked by a cross on a flat rock;
thence S. 25°04' W. 324.37 feet along and near the Easterly edge of said Mesa to a point
marked by a cross on a flat rock, the point of beginning.
Except instruments pertaining to Zoning or County Subdivision regulations in Garfield
County recorded or filed subsequent to December 15, 1970.
In GARFIELD COUNTY, COLORADO.
Owner - c,1
GARFIELD COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH
2014 Blake Avenue
Glenwood Springs, Colorado 81601
System Location
PERMIT # s 007
.. -) Ct t r �'�+1.. I _r\ d
SI w7 9 3 c 4
(this does not constitute
a building or use permit)
Licensed Contractor
* Conditional Construction approval is hereby granted for a gallon
Septic Tank or Aerated treatment unit.
Absorption area (or dispersal area) computed as follows:
Pere rate inches in minutes sq. ft.
absorption area per bedroom
# of bedrooms x sq. ft. minimum requirement
May we suggest
Date Inspector
FINAL APPROVAL OF SYSTEM:
No system shall be deemed to be in compliance with the Sewage Disposal Laws until the assembled system
is approved prior to covering any part.
Septic Tank cleanout to within 12" of final grade or aerated access ports above grade.
Proper materials and assembly.
Adequate absorption (or dispersal) area.
Adequate compliance with permit requirements.
Adequate compliance with County and State regulations/requirements.
Date _ Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All installation must comply with all requirements of the County Individual Sewage Disposal Regulations,
adopted pursuant to authority granted in 88.44.4, CRS 1963, amended 66.3.14, CRS 1963.
2. This permit is valid only for connection to structures which have fully complied with County Zoning and
building requirements. Connection to or use with any dwelling or structures not approved by the building
and Zoning office shall automatically be a violation of a requirement of the permit and cause for both
legal action and revocation of the permit.
8. Section III, 8.24 requires any person who constructs, alters, or installs an individual sewage disposal
system in a manner which involves a knowing and material variation from the terms or specifications con-
tained in the application of permit commits a Class I, Petty Offense ($500.00 fine - 6 months in jail or
both.