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• Lamont L. Kinkade, Sanitarian Y���
Gad. Cp. Environmental Health ���
2014 Blake Avenue Tel. 945 -7255
7 Glenwood Springs, Colo. 81601
NOTIVCATION OF PROPOSED DISCHARGE TO WATERS OF THE STATE*
INDIVIDUAL 'HOME SEWAGE TREATMENT SYSTEM ** .-
Owner: ! I r /14 at 1 L, L. S`J-ra kn�(A�P�L{ � ri /A IAA
Mail Address: ? 3n, G, 0 city a vAjnnnr1) U,lt 7ipAJh Phon e963 -?311
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 garkit-tel City or town
Legal description 70 C2c-aa-` Lot size
2. No. of bedrooms Septic tank capacity /on . 0 Aeration unit capacity
3. Source of domestic water: Public (dame): p hat (2 Wt I
Private: Well ✓ Depth ha Other Depth of first ground water table 1 7 Q
4. Is facility within boundaries of a city /town or sanitation district? O
5. Distance to nearest sewer system: `7 mi /Y s
Have you attempted to arrange a connection with the system? CIO
If rejected, what was the reason?
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 responsible for design of the system:
n 11 n 73 � si lau J. S tlr�� �.
�Date Signa re of
* Required by Article 66 -28 -12 (CRS, 1963, 1967 Pe . Sum. Supp.) �Yi3X ,
**Required in areas which have been identified as areas in which danger of pollution of
waters of the State may odcur (Art. 66 -28 -8 (5), CRS) and /or areas in which there is no
local septic tank ordinance.
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Please use the following space for directions to your property site.
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GARFlUd) COUNI'C L'1tV:1:R0 t L "'i.SL rl`.Al,]'t:
Field Test Data y, Sh �� eet � on Percolation Test
r PROPERTY OWNER M it'410 L r .& il��t4 JT rAVl1 PHONE *3' 9
MAILING ADDRESS P1-! y 60 , (nYbon d 4-4 1 r A 8/G 2 3
LEGAL DESCRIPTION OF PROPERTY S W '/W Se • l . E %2 S t '/y So e i 8
'/h NC /N Sec- 11 1,0,3 NW '/t SW ) /t sir 2 n nP 7 - a
LOCATION OF TEST HOLES
Three (3) test holes recuired per system
Teat Hole Depths (24" minimum) - - -- )
Diameter of Test Holes
Water Remaining after 24 Hour Soak
TEST HOLE N,1 _TEST HOLE Ik2 - - - - I —_ TEST H0140
prop Time D - row Time Drop Tine
rr -
i - - - - -
- _ 1
Percolation Rate Each Ilole
Average Rate
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LANE OF RESPONSIBLE PARTY RUNNING TEST PHONE. -_-
1
SIGNATURE DATE. t