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011Z.0RADO DEPARTMENT OF HEALTH
+inter Pollution Control Division
4214 East 11th Avenue
Denver, Colorado 80220
Building Official
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Owner: �n[1 ,2�1.., __ t
Clt
Mail Address: c3pt� /� yk,y, �.._,,,. Y. �X74 s Zipjrl�45 Phone
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
City or town
Legal description N N _ w Lot size
2. No. of bedrooms 4 Septic tank capaclty /7S0 6..Aeration unit capacity
(109rN/flue n � l r S O CIA
3. Source of domestic water: Public (name):
Private:: Veil )( Depth Other Depth to first ground water table
4. Is facility within boundaries of a city/town or sanitation district?1
5. Distance to nearest sewer system:
Have you attempted to arrange a connection with the system? #0
If rejected, what was the reason?
6. Rate of absorption in test holes shown on the location map, in minutes re:r Inch
of drop In water level after holes have been soaked for 24 hours_
2-01
7. Name, address, and telephone of person who made soil absorption tests:_
P7244? / r'
8. Name, address, and telephone of person responsible for design of the system:
D to 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
c'E.a.:r I bed on the front of this sheet and recommend approval or disapproval of
the discharge as shown below:
Date
Comments:
Approval Disapproval
•
Signature for Local Health Department
Signature for City/Town Official (Tit)
Signature for County Official --(Title
Signature and Title
Note: The Notifier (front of this sheet) must obtain comments and signature c at
least one of the above.
C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE:. Recommendations of the DistrL±: Fnglne,;r:
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMiSSION:
WP -33 (10-72-2)
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