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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 /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (System installed before 1/1/2000) <br /> Sanitary System Failure: (Mark correct response) <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES CO) <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES NO <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES <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 correc the best of my abilities. <br /> Plumber's Name(print) Plu •.- s S,, - - -• MP/MPRS#: Business Phone Number: <br /> 0I°Am S+ 30-7as 71 S'_ 46"07 <br /> Plumber's Address: City,State: Zip Code: <br /> c- -? I 1 i c)-4-.471 0,4,110.4- L cy c <br /> Burnett County Office Use Only: <br /> Approved ee Coll ied: DSPS Cred.No. Date Issued Iss ' g At Signa / / <br /> 0 Disapproved(Reason to be conveyed in I50 15;176 r f J�/� &4 , <br /> writing) C.�` <br /> Conditions of Approval/Reasons for Disapproval: <br /> Other Comments: <br /> Page 2 of 2 <br /> Reconnect Permit Application 12/2021 <br />