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Date=
Inspet-or
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REThl-'7F WIT*1 PVPMTIV RVC07.4017* AT CriNnTROC`TTON PITTr.
,'"lir COLORADO DEPARTMENT OF HEALTH
.Waher Pollution Control Division
) 21Q East ilth Avenue
' Denver, Colorado 80220
Owner:
Mail Address
;C—";31! Building official
NOTIFICATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL HOME SEWAGE TREATMENT SYSTEM**
£ t/V/► c`fl i/f
Cit
A. INFORMA ION 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 prof1les in test holes.
1. Location of facility: County f' ,,,; City or town ,12.1a )–
Legal description /.� ,,. .,,�; •..� Lot size___42, 5 0 f,4 ?'5
2. No. of bedrooms Septic tank pacity/e io Aeration unit capacity
•
Zip Phone
3. Sc,urcc of domestic water: Public (name) : id4i7
Private: Well Depth Other Depth to first ground water table
4. Is facility within boundaries of a city/town or sanitation district?
.3a.6i
5. Distance to nearest sewer system:
Have you attempted to arrange a connection with tips system?
If rejected, what was the reason? ------rte
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
Name, address, and telephone of person who made soil absorption tests:_
8. Name, address, and telephone of person responsible for design of the system:
4/---/s--- 7V
Date
eI�/ 5"C e
Sign ure ofd owner
*Required by Article 6 628-12(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 rtio local septic tank ordinance.
B. SIGNATURES OF LOCAL OFFICIALS: The undersigned have reviewed the notification
described on the front of this sheet and recommend approval or disapproval cf
the discharge as shown below:
Date
Comments: '
Approval Disapproval
Signature for Local Health Department
Signature for City/Town Official Title)
Signature for County Official (Title)
Signature and Title
Note: The Notlficr (front of this sheet) must obtain comments and siynatJre cf 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:
WP733 (10- 72-2) .
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