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le-1 • ?Lamont j., Kinkade, Sanitarian
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2014 Blake Avenue Tel. 945 -7255
Glenwgod Springs, Colo. 81601
NOTI$ICATION OF PROPOSED. DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME sSEWAGE TREATMENT SYSTEM **
Owner: Sf0 e @On(
8/1 eat, Ave
Mail Address: P.o, Drawer '790 City C /pk•koal s, lip Phone
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 (?ii .o J. City or town Cyl.trr, t—Aa(A
Legal description Rur - get EIS; iot✓t Lot size E.Scf. ✓IC
2. No. of bedrooms 2 Septic tank capacity /COG Aeration unit capacity
3. Source of domestic water: Public (name):
Private: Well )( Depth C Other Depth of first ground water table
4. Is facility within boundaries of a city /town or sanitation district? NU
5. Distance to nearest sewer system:
Have you attempted to arrange a connection with the system? VD
If rejected, what was the reason?
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
7. Name, address, and telephone of person who made soil absorption tests:
8. Name, address, a d telephone of person responsible for design of the system:
thAp,,.'F- �, IP-IACpt, Pte, /10? roo n /kp 1 9yC R /S'6•
5 73 � �� Q // . � At, 9.,/ rP Crhr
Date Signatu��,C/I Owner
* Required by Artidt 66 -28412 (OP' `, 1961, 967 "Perm. Sli m. Supk.3 -
** Required in areas which have been identified as areas in which danger of pollution of
waters of the State may opcur (Art. 66 -28 -8 (5), CRS) and /or areas in which there is no
local septic tank ordinance.
4 . .-i
Please use the following space for directions to your property site.
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