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Dispersal Component:(Does not apply to Holding Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) Cells Flooded/Ponded <br /> /2 2 Y /20c) a ct//s •X , <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (System installed before 1/1/2000) <br /> f j�OLI /OP ( AM,/ -,/ <br /> Sanitary System Failure: (Mark correct response) <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 all POWTS activity for which this permit is issued,and attest that all information <br /> stated on this permit form or on any attached documents is correct to the best of my abilities. <br /> Plumber's Name(print) Siuuahrfe MP/MPRS#: Business Phone Number: <br /> Plumber's Address: • City,State: Zip Code: <br /> /v t 4,i ter s vs-IL/ <br /> Burnett County Office Use Only: <br /> ' Approved Fee Collect DSPS Cred.No. Date Issued Issu g A.- t Signature <br /> 0 Disapproved(Reason to be conveyed in (So /5X77.26 <br /> I <br /> writing) <br /> Conditions of Approval/Reasons for Disapproval: <br /> Other Comments: <br /> Revised 8/5/20 <br /> Page 2 of 2 <br />