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COLORADO DEPARTMENT OF HEALTH an /7_3 Bo-° -a.r
Water Pollution Control Division 6 _ ,at
4210 East 11th Avenue
Denver, Colorado 80220 '7 `
APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS l�C2fl t
Applicant (Owner): (�,p i2
,, . hap
Mall Address: 31))( 897 City: Ortimil4s414 Phone: Ry5•7653
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, soli profiles in test holes.
l.4
1. Location of Facility: County L7 -1' v..tA City or Town N 1...se...27,- j
Legal Description ELI( C&EEIC" a. RIME Lot Size: Lan //0
2. Type of area and facility - Number of persons served:
Subdivision 5 Motel Restaurant Trailer Court
Other:
3. Source of domestic water: Public (name): ELK Ck.E &C '44 /t •y'T kl
Private: Well _ Depth _ Other _ Depth to first ground water table
4. Is facility within boundaries of City or Sanitation District: Nn
If so name:
5. Distance to nearest sewer system: 3--20z14-,-
Have negotiations been attempted with owner to connect: Wo
If rejected, give reason:
6. Rate of absorption In test holes 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:
9. Est. bid opening date 44TEst. Completion Date:2l3�� Est. Project Cost riot )r
Date: (a /o2V9e � ` r /
Signature of Owner
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is
B. SIGNATURES FOR LOCAL GOVERNMENT OFFICIALS: The undersigned have reviewed the
proposal for the location of the above - described septic tank system and
RECOMMEND APPROVAL or DISAPPROVAL in the space provided below:
DATE APPROVAL DISAPPROVAL
/-- / / - T
Signature for Local Health Department
/- /
Signature for Mayor or City Manager
/ _ 7
Signature for County Commissioners
Comments:
Signature and Title
Note: The applicant must obtain the comments and signature of at least one of the above.
C. FOLLOWING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
WP -10 (Rev. 5 -70 -100)