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CQLORA DO DEPARTMENT OF HEALTH
ater Pollution Control Division
4210 East llth Avenue
Denver, Colorado 80220
/e,'• -,e..(1-1 -' 0 0
APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTE
Applicant (Owner): /2419A-1/ /I Z41 L/7 i(./
Mail Address:/i4 /9i / City67-6a-JO0,, Phone: 4/_
S /2/s
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 Cade -2,<"16:/;.4" City or Town
Legal Description o95� Lot Size: / , /9(AY
2. Type of area and facility - Number of persons served: L7 - -e1'
Subdivision Motel Restaurant Trailer Court
Other:
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:
If so name:
/V'
5. Distance to nearest sewer system:
Have negotiations been attempted with owner to connect:
If rejected, give reason:
6. Rate of absorption in test holes in minutes perinch 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: Est. Completion Date: Est. Project Cost:
Date:
/54; /97_13
Signature of Owner
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 D[SAPPROVAL in the space provided below:
DATE APPROVAL DISAPPROVAL
Comments:
Signature for Local Health Department
Signature for Mayor or City Manager
Signature for County Commissioners
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)