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CO
COLO?AU0 DEPARTMENT OF HEALTH
Wa *r Pollution Control Division
4210 Ea5e 11th Avenue
Denver, Colorado 80220
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Mail Address:.��4X_/ 3 7 Cl ty IF/ Zip 8'f 5 Phone ‘,-25-/.5-yy-
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)'+/ORif I.G ,v_-Gl,Boci• Lot size .2
2. No. of bedrooms Septic tank capacity br6 o Aeration unit capacit
'J c-1 G
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?/✓O
5. Distance to nearest sewer system: • �� �•
Have you attempted to arrange a connection with the system? 4410
If rejected, what was the reason?
r--
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
/414 7I '7
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:_-___
7% 6 a
ure t� 4 ------
Date
Signa o 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.
ati
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
Signature for Local Health Department
Signature for City/Town Official TTltie)
Signature for County Official (Title
Signature and Title
Note: The fotlfier (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)
4
.104
GARFIELD COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH
2014 Blake Avenue
Glenwood Springs, Colorado 81601
Owner L t Aar' en- Ct.r 1
PERMIT # S 032
(this does not constitute
a building or use permit)
System Location' 1V I -31-7 1;') t P
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 66.44.4, 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.
3. Section III, 3.24 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 1, Petty Offense ($500.00 fine - 6 months in jail or
both.