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ont L. Kinkade, Sanitarian
t . Co. Environmental Health tatei t,
2(1,+ Blake Avenue Tel. 945 -7255 t
enwood Springs, Colo. 81601
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NOTISICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM **
Owner: ?Tnlnic j. F/S-\gei >�c b
`1 (�+ ca =7,33
Mail Address: /Crew:
f �pr rt /�ro�.r� City ieva.9oaJ ,5?, > /�cyipFS bo/ Phone 75PTi
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 6..4., ,vc.omm.b
Legal description/ve 'sr .q 7S. fz3 ? L9 . Lot size 4 4s 4c S -
' 2. No. of bedrooms ,V Septic tank capacity /COO Aeration unit capacity=
3. Source of domestic water: Public (name):
Private: Well V Depth 175 Other Depth of first ground water table iy$'•
4. Is facility within boundaries of a city /town or sanitation district? Nn
5. Distance to nearest sewer system: -
Have you attempted to arrange a connection with the system ?, /n-
If rejected, what was the reason? t.5 . 79-./3/0 .=
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
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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:
C / - 73
Date Signature of Owner
*Required by Article 66 -28 -12 (CRS, 1963, 1967 Penn. 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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Please use the following space for directions to your property site.
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