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CITY OF SILT DEPARTMENT OF ENVIROMENTAL HEALTH
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401 Main Street, Silt
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CITY OP SILT DEPARTMENt OP ENVIRONMENTAL HEALTH
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CQLO.RADO DEPARTMENT OF HEALTH
WatierrPolluti.on Control Division
44210 East llth Avenue
Denver, Colorado 80220
dleMea-
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
Owner: )G �� q�C.S #ta e Sr;;_
Mail Address: 'Boll( 277 City 5L4r Z14/4.5%2Phone l ;WV
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 fact l lty: County41Rprea 'CI ty or town 4:7-"
Legal description ' 4,s.e4 Lot size
2. No. of bedrooms 2 �tcapacity_L Q0 Aeration,unit capacity
3. Source of domestic water: Public (name): % 0
Private: Well Depth Other Depth to first ground water table
4. is facility within boundaries of a city/town or sanitation distric071/4.11
3Qo x"414
Have you attempted to arrange a connection with the system?r1Sr�.'_..________�
if rejected, what was the reason?
6. Rate of absorption in test holes shown on the location map, in minutes per loch
of drop In water level after holes have been soaked for 24 hours_ __----
5. Distance to nearest sewer system:
7. Name, address, and telephone of person who made soil absorption tests:
8. Name, address, and telephone of person responsible for design of the s stem:
7
Date
9
ature of Own
*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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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 Officia E Title)
Signature for County Official Title
Signature and Title
Note: The Notifier (front of thIs sheet) must obtain comments and si'nature 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)