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Lamont L. Kinkade, Sanitarian 4 Qt ,1
f. Co. Environmental Health � f��
2014 Blake Avenue Tel. 945 -7255 ' ` '
Glenwood Springs, Colo. 81601
NOTIlICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVITSUAL HOME SEWAGE r :120P4 /q / TREATMENT SYSTEM **
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Owner: �i �/ sr '�A)
Mail Address: a */ %' i 7 City /j4a / J c s 4 zip & /lp'7Phone
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 64 pp/ t / City or ttownJ4.4) C/17 t_
Legal description /4"$ E/Zk) s E / S 1 9 4 Lot size i �r
2. No. of bedrooms / Septic tank capacity 75 Aeration unit capacity
3. Source of domestic water: Public (name):
Private: Well - Depth CO Other Depth of first ground water table
4. Is facility within boundaries of a city /town�or sanitation district? Kit)
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5. Distance to nearest sewer system: /'7' 1 !'!/
Have you attempted to arrange a connection with the system? A'O
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:
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8. Name, address telephone of person responsible for design of the system:
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,pate Signature of Owner
* Required by Article 66 -28 -12 (CR 1963, 1967 Perm. Sum. Supp.)
**Required in areas whiofo h9vs beitadentified 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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