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Largo t L. Kinkade, Sanitarian p
Co. Environmental Health / /T /D 7 -/673i
2014 Blake Avenue Tel. 945 -7255
Glenwood Springs, Colo. 81601
NOTItICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME / $ , EEWAGE TREATMENT SYSTEM **
Owner: tic4.1 27t/,,A, e G/ € ��O x
Mall Address:/( #/ `} O X 7 r City (rlpM4,,,, Phone ?jets 3
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 welts, soil percolation
test holes, soil profiles in test holes. ( 1. Location of facility: County (} e9x T / P /o / City or town ._y_ y
Legal description Lot size _2 cry /9e /t p s
2. No. of bedrooms 3 Septic tank capacity Aeration unit capacity
3. Source of domestic water: Public (name):
Private: Well Depth Other e'>9 epth of first ground water table
4. Is facility within boundaries of a city /town or sanitation district? WO
5. Distance to nearest sewer system: F_ S/ C .1,0 /to s �1
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
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:
`/ 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 ogcur (Art. 66 -28 -8 (5), CRS) and /or areas in which there is no
local septic tank ordinance.
Please use the following space for directions to your property site.
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THE FOLLOWING DESCRIBED REAL ESTATE
SITUATED IN '
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11 1
GARFIELD COUNTY, COLORADO . j r
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as, Lots•3 and 4 Section 20; Lots 4 and 5 Section 29; Lots 1, 2, '+•.' \ 4
3, 4'"and that part ofLot 6 lying North and Northeasterly of t a - F_
/ . �: County Road, Section 30; Lots 5, 6, 7, and 8, Section 19; al=' >.
T ownship 6 South Range 88 Weat of the 6th "Principal Meri- 07...'.K
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-i :•.' Also conveys Lots 6, 7, 17, and 19 Section 29; Lots 7 and ,..
-,.i(' " : ,, 8 Section 30; Township 6 South Range 88 W. of the 6th Pdin- Vii : +
cipal Meridian. '` )• a
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EXCEPT that part deeded out by Document No. 132942 and Doc- m
ument No. 132635.
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