HomeMy WebLinkAboutpitkin.eh.264335203001 (1972)_APPL FOR SEPTIC LOCATIONPd '3�Z o3 -10l
COLORADO DEPARTMENT OF HEALTH
Water Pollution Control Division
4210 East 11th Avenue 3/5 _RK SSY1 Dr
Denver, Colorado, 80220
APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
Applicant (Own
Mail Address: City:
A. INFORMATION REGARDING PROJECT SUBMITTED FOR REVIEW:
Phone:
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 4�? / /,4 Ci ty or Town ;2 Al
Legal Description / j f" S;j J S"gd we z) Lot Size: c,NES
2. Type of area and facility - Number of persons served:
Subdivision Motel 4LIL.— Restaurant /'! Trailer Court
Other:
3. Source of domestic water: Public (name) :A �,, �, �� ,,,13t
Private: Well L Depth Other _Depth to first ground water table
4. Is facility within boundaries of City or Sanitation District: /a/0
If so name: ,2/
5. Distance to nearest sewer system: 2121 1�
Have negotiations been attempted with owner to connect:
�t
If rejected, give reason: 4Z�
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, addre�s d telephone of person responsible for design of the system:
9. Est. bid opening date: Est. Completion Date: Est. Project Cost:
l
Date: i2 - / `y-� _
Signatur6 of Owner 7.1,�