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'4/ COLORADO DEPARTMENT OF HEALTH
Water Pollution Control Division
4210 East 11th Avenue
Denver, Colorado 80220
APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
App lcant (Owner): C0 4.0 an• 10
APe c A)/ sc go,
Mall Address: /ev1T. 1/ eo)( ' City: CA4 I 4L.e. Phone: 7/7 2.5-63
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,;oll profiles In test holes.
1. Location of Facility: County 6.44 C r e Ld City or Town
Legal Description Lot Size: / 360 rr
2. Type of area and fa'cllity - Number of persons served:
Subdivision Motel Restaurant Trailer Court
Others 4=4,1 y yv
3. Source of domestic water: Public (name):'
Private: Well Depth Other Depth to first ground water table
4. is facility within boundaries of City or Sanitation District: O
If so name:
5. Distance to nearest sewer system:
Have negotiations been att1 mptsd with owner to connect:
If rejected, give reason:
6. Rate of absorptl& in test holes In minutes per inch of drop in water level after
holes have bssn,oaked for 24 hours:
Edi
7. Name, address andstelephons of person who made soil absorption tests:
O. Name, address end telephone of person responsible for design of the system:
9. Est. bid opening date:
Date: -2-4 7 3
Est. Completion Date: Est. Project Cost: r.... --.r
�.�.« -->• - i
gnature o wnsr
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
Comments:
APPROVAL DISAPPROVAL
/1 /-7
Signature for Local Hearth Department
a it
1 gnature for Mayor or C ty Manager
S gnature or County Commissloners
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)
GARFIELD Ct.UidTY 1~IIVIROI1 :tiTAL
Field Test arta Sheet on Percolation test
PROPERrx Di;'r:ILR 1>llOr;f_
1 iAILI1 Iv ADDRESS
DE:XR11 TION OF PROPERTY
i •CK:A'1. CiT GF TEST HOLES
Alit;, (2) to:,'. holes required per sys'srrn
Trzt Hole Dcptha-- -.•---
kilometer_ of test holes, ,uggest 1' ----�_--�..
1ctcr he"•;d.ni.ng after 24 hour -----
Safi innicateti adequate Dorking
TEST IOLL I#
ME°2
j in.
r . in.
: I.11r
rI1it..
r :1 i,..
6 in.
r e I. .
T�_•-�.
fi.in.W
Tim
i-S11E�tcs
firtte Aver iqc• Lac', o)e
t: L.a.q.•iricd Rate:
Zt.. i i)t .Sc't'IFitjon -
4' Tani.. tm
t"��,~_ ;c t:'•.. s ( ;'ei.1.�, Strep .as, later Table, i nr r i n etc..
.'es
:^1:S T HOLE #f 2
NO
I;r Tine ;dn.
1 tn. .-..
1 in.
3 1.n.
1; In.
5 in.
6 in.
7 in.
G In.
9 •..
-10 5.1..
11 tn.
IP in.
;!NTE OF PARTY RUNIIUL TEST PWOUE
SIGNATURE:
DATE
.01.001
.1.101.000