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,o COLORADO DEPARTMENT OF HEALTH V �°��
Tr "'Water Pollutlorl Control Division
•4210 East 11th Avanua ; �.'�w
,b Denver', Colorado "00220 "�a:
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III NOTIFi CATION OF PROPOSED.'ISCHAROE TO WATERS Of THE' #
"l E ' GE TREATMENT SYSTEM ** " ' fV ''
` -11 Owner: NEA)Q/C T A CAkC• . Ra•ko A-10 6/4Z Kb Mc PARl< 4 4 Tr '
Sr.
�N "hL ", :.,.
y•" Mal Address: C /ct Afowcf City ,SPK+I GS Z ip R#5.0/ Phone S0,%,,l ... �
e rt l A. INFORMATION REGARDING PROJECT SUBM * TED FOR REVIEW: i 6 „
:41i 1 I4
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I v Attach separate : sheets or report s"owwing ehtlre area with respect to surrounding �
4 areas, topography of area, habltab,0 buildings, location of potable water wells, .iw l' F I'p '.
• soil percolation test holes, soil raffles to test holes. ' 1 1144
" I' 1. Location of faci l lty: County E 1c nP L;,.(> City or town G 0s4h: A n9f) SPG-S , ;'Y*,y •
Legal description '/ 4 5Sc Tr 6 R84:60 Lot size .
lE4V N,� 1
' * 2. s Septic tan capacity Aeration unit capacity / f
0
" . a Ears- r:1J11+ b4bis,1.0 HokssS t'W% , FIGURED FAR (00 -roTAL PeRs0ai.' ` " +"f''! ALL.
" . 3. source of domestic water: Public ,name) : . d '/'A " "M lle � .4 P'
( " - 1 " „ I i" fl.
I +• t" Private: Weil„X,_oepthrp Other Depth to first ground Water table _ I Ir'uI' II, ry f
_TI, 4. Is facility within boundaries of a,clty /town or sanitation district? N0 • ,,,IV
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.lI, 5. Distance to nearest sewer system: + M) LE S 11,1"Aq°
I�1 Have you attempted to arrange a connection with the system ? k) {4
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„ lq �I
,I If rejected, what was the reason/ , �;I
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4I 6. Rate of absorption In test holes - shown on "the location map, in minutes per Inch mk I'i.
-Al of drop in water level after holeslhave been soaked for 24 hours 10 I '- ,
'v
7. Name, address, and telephone of pe who made soil absorption tests: t , I ^ " '
IP ti
4 8. NameDDSW REERtD$RDpInhMDe ofo rson 'respond for design of the system ' "
Pi O, Box 248 I d
ovwOOD3PId1400 C0I0.01601 ra
ic : 11t I°
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� Da a I tgnatu A o Owner a m
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*Required by Article' 66- 28- 12(CRS, 1963, 1967 Perm. Sum. Supp.)
* *Required In areas which have been idei tilled ,as areas In which danger of pollution ' 4
of waters of the State may occur (Art 0 66- 28 -8(5), CRS) and /or areas In which there I.
Is no local septic tank ordinance. .,,1 II II
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B. SIGNATURES OF LO9AL.OFFICIALS: The undersigned have reviewed the notification
described 9n the &;ront'of this she & "t and recommend approval or disapproval of
the discharge as shown below:
Date Approval. Disapproval
•
" Signature for Local Health Department
Signature for City /Town Official (Title)
a ,p
Signature for County Official (Title)
" Comments
Signature and Title
Note The Notlfaer (front of this sheet) must obtain comments and signature of at
least one of the above.
C. FOLLOWING POR STATE HEALTH DEPARTMENT USE: .Recommendatl'ons of the District Engineer :'!
•
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
`' ; WP -33(IO -72-2)
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