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COLORADO DEPARTMENT OF HEALTH
Water Pollution Control Division
4210 East llth Avenue
Denver, Colorado 80220
Ale, 7 ' /Yews' 4 csc,,. v et i PC) t, C n
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APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
Applicant (Owner): MR_ '•T F PIIEL L) ()1
Mail Address: 6920 VA:ET E POO City: F3C il4En A Phone:
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW: J�4 R [�� '2 c
Attach 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.
1.
� Mr ( tZT3
Location of Facility: County t-fgI F= IEL,D City or Town CAUL)P L,F
Legal Description , jk1T-.. `tlIl/2 4JZV l l) 7o Lot Size: 4`) AG,
2. Type of area and facility - umbe��persons served: 4 "
Subdivision
Motel Restaurant
Other: E 6Ertile01.4
Trailer Court
3. Source of domestic water: Public (name):
-f 'Ch'
Private: Well Depth Other Depth to first ground water table
4. Is facility within boundaries of City or Sanitation District:
If so name:
5. Distance to nearest sewer system:
NO
Prros 1411,Es To (?iiQRnuak,F
Have negotiations been attempted with owner to connect:
If rejected, give reason:
6. Rate of absorption in test holes in minutes per inch of drop In water level after
holes have been soaked for 24 hours:
iD
ul9<ii
7. Name, address and telephone of person wholmade soil absorption
ROY
EMO 9c,s-6,7112
tests:
8. Name, addrss and telephone of person responsible for design of the system:
9. Est. bid opening date:
Date:
Tote? 7, //75
Est. ComplettonnDatg'r - E Project Cost:
t/--
ignatuje of Owner
0-'11 I IX 1-n Ire
.n
B. SIGNATURES FOR LOCAL GOVERNMENT OFFICIALS: The undersigned have reviewed the
proposal for the location of the above-described septic tank system and
RECOMMEND APPROVAL or DISAPPROVAL in the space provided below:
DATE APPROVAL DISAPPROVAL
-7
Comments:
/-7
Signature for Local Health Department
S gnature or Mayor or C ty Manager
S gnature or County Commiss oners
• .f '._. 4
Signature and Title
Note: The applicant must obtain the 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 -l0 (Rev. 5-70-100)