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6O PITKIN AVENUE
ULENWOOD SPRINGS OOLORAY
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AM, CATI08: FoR INDIVID:JAL SE E DIS AL SYSTEE PERRIT
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liFCEIPT # ./J64 ,
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All ittd-VVit a ticetrage disposal permit Ls hereby submitted° 'i'•
• ,,, e(0 du;posa. yston will be constructed in accordance with the
4; -- k: ; nte: comer/not ina) ‘newil sewage disvosal eyebeme within Garfield Const.y
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lu valid rot Fii. (6) nonths iron date sUnedn
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PLOT oi,,A;,
amont L. Kinkade, Sanitarian
r#. Co. Environmental Health
2014 Blake Avenue Tel. 945 -7255
° Glenwood Springs, Colo. 81601
NOTI$ICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVITSUAL HOME SEWAGE TREATMENT SYSTEM **
Owner: l/ -c- .�i�i�i�7 C
Mail Address: City 7 77 (0c9 lip Phone e- sr
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 G,4Z3fiL7 O City or town
Legal description Lot size
2. No. of bedrooms Septic tank capacity Aeration unit capacity
3. Source of domestic water: Public (name):
Private: Well d Depth Other Depth of fjrst 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? —
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 wends e7 nor cv �
7 - ate C e71CC_
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:
�r' �(�� 4 . t5-1 &� r /�.c) e s/57 ?7n_5
2-,
Date 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 oticur (Art. 66 -28 -8 (5), CRS) and /or areas in which there is no
local septic tank ordinance.
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• Please use the following space for directions to your property site.
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