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CcILORADO DEPARTMENT OF HEALTH
-Wafer Pollution Control Division
' 421.0 East 11th Avenue
Denver, Colorado 80220
Owner:
'X6-;Zie k‘c_cal.
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
We-615441)L� Mall Address: r0 a!' )c 7 C1ty oZ1P �62Phone 91.r.-6375-
wo
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* City or town
Legal description ficLf Ll/ .- AREA Lot size eU A
2. No. of bedrooms 0 Septic tank capacity
3. Source of domestic water: Public (name):
Private: We11a 2 Depth/O, Other Depth to first ground water table__
4. Is facility within boundaries of a city/town or sanitation district?__J
5. Distance to nearest sewer system:
Aeration unit capacity___
Have you
attempted to
arrange a connection with the system?
If rejected, what was the reason? 4-0
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
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Date Signature ofritrcr f`
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gelt
`Required by Article 66-28-12(CRS, 1963, i967 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.
responsible for design of the system:
B. SIGNATURES OF LOCAL OFFICIALS: The undersigned have reviewed the notification
described on the front of this sheet and recomruend approval or disapproval of
the discharge as shown below:
Date
Comments:
Approval Disapproval
1..
Signature for Local Health Department
Signature for City/Town Official (Tit3e)
Signature for County Of; ir.ie1 (Title)
Signature and Title
trate: T:,c t:;t;`lcr (front of his sheet) must obtain comments and signature of at
lE.E.st one of the above.
C. FN.1o',ING FOR STATE HEALTH DEPARTMENT USE: Recommendations of the District Engineer:
D. ACTION BY THE COLORADO WATER POLLUTION CONTROL COMMISSION:
WN33 (10_72.2)
i4
GARFIELD COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH
2014 Blake Avenue
Glenwood Springs, Colorado 81601
PERMIT 0 8 012
Owner /t )1'> ( • [(, ..; C 'bi c
System Location (..00. "i �-)l -N 4[ (-1
Licensed Contractor
(this does not constitute
a building or use permit)
* Conditional Construction approval is hereby granted for a gallon
Septic Tank or Aerated treatment unit.
Absorption area (or dispersal area) computed as follows:
Pere rate inches inminutes sq. ft.
absorption area per bedroom
# of bedrooms x sq. ft. minimum requirement
May we suggest
Date Inspector
FINALL APPROVAL OF SYSTEM:
No system shall be deemed to be in compliance with the Sewage Disposal Laws until the assembled system
is approved prior to covering any part.
Septic Tank cleanout to within 12" of final grade or aerated access ports above grade.
Proper materials and assembly.
Adequate absorption (or dispersal) area.
Adequate compliance with permit requirements.
Adequate compliance with County and State regulations/requirements.
Date .Inspector
RETAIN WITH RECEIPT RECORDS AT CONSTRUCTION SITE
*CONDITIONS:
1. All .installation must comply with all requirements of the County Individual Sewage Disposal Regulations,
adopted pursuant to authority granted in 66.44.4, CRS 1963, amended 66.3.14, CRS 1963.
2. This permit is valid only for connection to structures which have fully complied with County Zoning and
building requirements. Connection to or use with any dwelling or structures not approved by the building
and Zoning office shall automatically be a violation of a requirement of the permit and cause for both
legal action and revocation of the permit.
3. Section III, 8.24 requires any person who constructs, alters, or installs an individual sewage disposal
system in a manner which involves a knowing and material variation from the terms or specifications con-
tained in the application of permit commits a Class I, Petty Offense (8500.00 fine - 6 months in jail or
both.
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