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Dispersal Component(Does not apply to Holdin Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> 12/36 <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/1/2000) <br /> AVi t s/�`� z 4 ,1V0(tA/C ' <br /> Sanitary System <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES X10 <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES `� <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> Plu s Name(print) Plu Signature: MP/MPRSW No.: Business Phone Number: <br /> /0iLl-def 4--P<-/-7 Pfri 95-/-1 7.16%-.36'0204 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> (04117471/4J.t)Z-ie ' tije4Ar 5%13 <br /> Office Use Only: <br /> 0 Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> Approved ❑Owner Given Reason for Q <br /> Disapproval in Writing /5PA 1$4 • /• <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />