HomeMy WebLinkAboutApplication-Permit..*
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Jesse Markum
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cigariy part thereof.
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' COLORADO DEPARTMENT OF HEALTH
Water Pollution Control Division
4210 East lith Avenue 9C20.v1At(.t)Z Building Official
Denver, Colorado 80220
&c.06, POtc4 T POST tet) DA --r 5{ car- r,
Owner:
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Mail Address:/;75-(5 cce.AA Clty` / ,far Z i p fl 7 Phone 9J4",-2 yaj""
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW:
Attgh 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.
. Location of facility: County �jC��i" �'" city or town
j
t ," ' Legal description Lai 4 /ock z glieffikinw&lot size
2. No. of bedrooms 3 Septic tank capacity Aeration unit capacity
3. Source of domestic water: Public (name): r iZ_€1
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:
Have you attempted to arrange a connection with the system? /j'lj
If rejected, what was the reason?
6. Rate of absorption in test holes shown on the location map, in minutes pnr inch
of drop in water level after holes have been soaked for 24 hours_____
S
4? -7 P olt. 4A ,1
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:
Cl- /5 -74-/
Date
Signature of OwOrr
*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.
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D. SIGNATURES OF LOCAL OFFICIALS: The undersigned have reviewed the notification
described on the front of'this sheet and recommend approval or disapproval of
tie discharge as shown below:
Date
Comments:.
Approval Disapproval
Signature for Local Health Department
Signature for City Town Official TTit e}
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(10-72-2)