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Mrs. Katherine Hendrick Box 477 Carbondale, CO
Western Pioneer Corisglirigbon
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De.te Into
2. ,1 Lpproval of Syntom:
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Vc7 3yotc shall he d.T.c.„msd to he in compliall vith the rcr-j
Laws until the ass$et.abled cystem is app?,:ovc, p)7i:)r
oing any part thereof.
septic tank eleanont with eel sosal
6L1___. Proper materials and assemb3
L. Aelpsplp,_te It'psorpfr4on area
Adegt,tate concrete cover_,(dly_tit.b.3.2„s._.,c,..A.1y).______
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CQLQRADO DEPARTMENT OF HEALTH
Wates. Pollution Control Division
4210 East 11th Avenue
Denver, Colorado 8022C
Owner:
Building Official
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Mall Address: 3x 477
CityC'•a2BC)AIAA(.EZipc3/(,23Phcnej -2 00
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW:
Attach separate sheets or report showing entire area with respect to surrounJing
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 ' ,RFjez_f City or town lv � CAV410,Nn/rtk7
0,11 OS PM.
Legal descr I pt I on Ser -r10 Tu►hs3,� S S. R. U) /i Lot s I ze 4s.cKc
2. No. of bedrooms 2_ Septic tank capacity Aeration unit capacity
3. Source of domestic water: Public (name):'"
Private: Well Depth Other Depth to first ground water table
4. Is facility within boundaries of a city/town or sanitation district? do
5. Distance to nearest sewer system:
Have you attempted to arrange a connection with the system?
If rejected, what was the reason?
6. Rate of absorption In test holes shown on the location map, in minutes per Inch
of arop in water level after holes have been soaked for 24 hours
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7. NOW., address, and telephone of person who made soil absorption tests:
8. Name, address, and telephone of person responsible for design of the system:____
({�r-vfDate lt to , (74--
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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.
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8. SIGNATURES OF LOCAL OFFICIALS: The undersigned have reviewed the notification
described on the front of this sheet and recommend approval or disapprovc.i of
the discharge as shown below:
Date
Comments:
Approval Disapproval
Signature for Local Health Department
Signature for City/Town Official ITY1-1)
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.
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)
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