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�• C�LORADO DEPARTMENT OF H OTH
Water Pollution Control Division
4210 East 11th Avenue
9enver, Colorado 80220
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APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
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Applicant (Owner): zj,l-,,V'T
Mai l Address: y��, S— CI ty:� Phone: 121,q
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 ^yc 1, . Ci t or Town /,.4"_
Legal Description '-�7/// . Lot Size: , /,7 x -s /J '
2. Type of area and facility - Number of persons served:
Subdivision 1/% Motel ,q Restaurant �/,Q Trailer Court Z//4.
Other.
3. Source of domestic water: Public (name):
Private: Well _Z Depth Other *�7 Depth to first ground water table /,S-
4. Is facility within boundaries of City or Sanitation District:
If so name:
5. Distance to nearest sewer system:
Have negotiations been attempted with owner to connect: '�71A
If rejected, give reason: �I / d_
6. Rate of absorption in test holes 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:
9. Est bid opening date: _ Est. Completion Date: Est. Project Cost:
Date:
Signature of Owner
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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 APPROVAL DISAPPROVAL
Signature for Local Health Department
Signature for Mayor or City Manager
Signature for County Commissioners
Comments:
gnature 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:
I oy� WP -10 (Rev. 5-70-100) ,
T. 8 S., R. 84 M. OF THE 6TH P.F'ILM.
�, ry �S. S9' 34.20 E. 158.79
REQUIRED rOC40SZ
ORIGINAL TRACT
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ORIGINAL r? ACT b
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MAP OF TRACTS OF LAND
situoted in
SEkSEJ OF SECTION 11
T, 8 S., R.•84 N. OF THE 6TH P. M,
PITKIN COLfMo COLORADO
SCALE: 1 Inch ■ 50 feet
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MAP OF TRACTS OF LAND
situoted in
SEkSEJ OF SECTION 11
T, 8 S., R.•84 N. OF THE 6TH P. M,
PITKIN COLfMo COLORADO
SCALE: 1 Inch ■ 50 feet