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• . Carl E. Ward P.O. Box 147
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COLVRAM C E.PAI TNENT .OF HEALTH
• Wader Pollution Control Division
421Q Fast )1th Avenue
''Deriver, Colorado 80220
Building Official
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Owner: OM/ / tinged
Mall Address: PO .go/ /47 city lZ I p g./Lc4Phone943-c,ZOM
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 k_Debei/Ccie� City or town
Legal description c CO
%4 fc./7`�1 /7—t6 -4 7066t size 5"4DAc. e r-4
(1J}i
2. No. of bedrooms , . Septic tank capacity Aeration unit capacity
3. Source of domestic water: Public (name):
Private: Well)( Depthi''Other Depth to first ground water table //)i
4. Is facility within boundaries of a city/town or sanitation district?
5. Distance to nearest sewer system: // ,t/F_ APV0 &e_.
Have you attempted to arrange a connection with the system? /y0
If refected, 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:
Az,
Name, address, and telephone of person responsible for design of the system:
4ii.'i/ /e, /De1
/.91a.:A.Je
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 notificatioi
described on the front of this sheet and recommend approval or disapprove' :f
the discharge as shown below:
Date
Comments:'
Approval Disapproval
Signature for Local Health Department
Signature for City/Town Official TTitie)
Signature for County Official tTit1e)
Signature and Title
Note: The Notifier (front of this sheet) 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(10-72-2)
7s; dug 60.din
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