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c fl$KAD° DEPARTMENT OF HEALTH r1,41/ rQ •
Water ?.dilution Control Division • tjn,,7 4.1,.°
421Q East llth'Avehue , a nti
7 Denver, 'Colorado 80229, ^
MAW a� - < •
q r' frib�AT'i0N OF PROPOSFD- DISCHARGE TO WATERS OF THE .STATE*
i INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM **
Mall Address: 071/4 jt -.( 1 ,a-7' ri . City Zip I(64.q Phone S'=
iu' A. INFORMATION REGARDING PROJECT SUBMI 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.
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1. Location of facility: County _City or town _______'r1°I+ l •
Legal description Cxr°/ Ak ./i, , Lot size 3
s `76
2. No. of bedrooms Septic tank oapaclty Aeration unit capacity ^'
3. Source of domestic water: Public ) (name):
Private: Well ie diepth Other Depth to first ground water table
4. Is facility within boundaries of a city /town or sanitation district?
5. Distance to nearest sewer system J,1oai .-
Have you attempted to arrange a connection with the system? ,'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
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7. Name, address, and telephone of person who made soil absorption tests:
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8. Name, address, and telephone of person responsible for design of the system :_
Date ; 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 occur (Art, 66- 28 -8(5), CRS) and /or areas in which there
Is no local septic tank ordinance.
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B. SrGNATURES,OF= O CA(. OFFICIALS: The.undersigned' have reviewed the notification
described on the front of this shea and recommend approval (or disapproval of
r the discharge as shown below:
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Date Approval D1sapproval
• Signature for Local Health Department
p �' Signature for City /Town Official (Title)
" Signature for County Official (Title)
R Comments:
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" Signature and Title
" Note: TheNotlfier (front of this sheet) must obtain comments and signature of at "
" least one of the above.
C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer:;;,' {',
.ills
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4 D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION: , o
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Wp" 33 (10 -72 -2) 1,„ .