HomeMy WebLinkAbout710419.tiff LUrw w DEPARIMtNi 1EALTH
Water Pollution Control Division -
4210 East 11th Avenue
Denver, Colorado 80220
APPLICATION FOR APPROVAL OF LOCATION FOR SEPTIC TANK SYSTEMS
Applicant (Owner) : Sc..Iw1llc,( 7` /x # Fc,1rr e ; ?- -'sue U. L lec ii ;r1 e
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Mail Address: 16 L3Cy (ri/ City: F+_ )-u pi(irt Phone: 5;c1-_,:lo2
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 \2jE? jot City or Town r- . 1--Iy 4 6 IN
Legal Description Sub//� , `-, ( J!C! S J— /nio Lot Size: 2' o C0 rQ_ 5
2. Type of area and facility - Number of persons served:
Subdivision /;, si {-e3Motel Restaurant Trailer Court
Other:
3. Source of domestic water: Public (name) :
Private: Well l/ Depth .,---;_c/Other Depth to first ground water table . / 47
4. Is facility within boundaries of City or Sanitation District: I'2 p
If so name:
5. Distance to nearest sewer system: / u�''
Have negotiations been attempted with owner to connect: it ,
If rejected, give reason: el'o,l (,;.ylICii: )IL o
i-tf -Pea ,- I (� C_/
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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:
Lo ry ,Se h u a l c,V 1 +. c_f) //t'rLe-- i (vi o )n r s, (10
8. Name, address and telephone of person responsible for design of the system:
(1,90 k---- Gouty( v a Li ' 'r ° nlP ) t �.._
I
9. Est. bid opening iaate: U Est. Completion Date: Est. Project Cost:
/�� IC
Date: J`iu� ul�� � � ) �r '7L ��/� , �. � ,.vr.,.,
/ Signature of Owner \ �//' J/
e ",yam .
710419
b. .._.., IVA LOCAL GOVE •c„ V.i:L„-.._�. �,,c;�'i gf1! ave rev t;.rt�u �11:
proposal for the location .,r the above-described septic tank system and
RECOMMEND APPROVAL or DISAPPROVAL in the space provided below:
DATE APPROVAL DISAPPROVAL
/6 /7 / / - f
Sig to e for Local ealth Dep rtment
/- / / /
Signaturefor Mayor or City
ty Manager
/ / / / 7,/,
/5iTa/ture tor 'County Commissioners
Comments:
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-1O (Rev. 5-70-100)
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