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• Dispersal Component(Does not apply to Holding Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> System Elevation i ation to Soil Bonin ark Information <br /> (ONLY for tern installed before 1/1/ 00) <br /> Sanitary System <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES NO <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES NO <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES NO <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the PO S acct r which this permit is issued. <br /> Plumber's Name(print) Plumb-• i Ftur• MP/MPRSW No.: Business Phone Number: <br /> Ct 233 7).S.- 71-5. 6 9, (197) <br /> Plumber's Addre44(Street,City,State,Zip Code): <br /> 02 S7 ( US- --(e &DiOffice Use Only: <br /> 0 Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> Approved 0 Owner Given Reason for !9 <br /> Disapproval in Writing l ' 3 li y. 2/.Z/ 113.4i <br /> Comments: w <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />