Laserfiche WebLink
Dispersal Component: (Does not applto Holding Tanks) /,�cr),,t' rA--02.1.1ve‘. <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) Cells Flooded/Ponded <br /> lla �X ,a 6 a a. N'o <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (System installed befpre 1/1/2000) <br /> 1/I ` fOP o7 /irk 14 v Puy-LP 7)k <br /> Sanitary System Failure: (Mark correct response) <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES 1011 <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES �N�O <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) Plumber's S. atur . (/MPRS#: Business Phone Number: <br /> & b V a fit'i4-iod o3s7 yrs-760 O <br /> Plumber's Address: City,State: Zip Code: <br /> / &)( 47`/3 /1 .�f Y 5e//� ( <br /> Burnett County Office Use Only: <br /> Approved Fee Collected: DSPS Cred.No. Date Issued Issuing ent Si: •tu� <br /> 0 Disapproved(Reason to be conveyed in 4150 153o 771 8/30r � I <br /> writing) 15;7'15 [Jl <br /> Conditions of Approval/Reasons for Disapproval: P <br /> �lee� 41' 5e4-b4 <br /> Other Comm nts: oµ�d , a� 1e r <br /> 5e a Co ol✓ner o� ► pr./ <br /> Page 2 of 2 <br /> Reconnect Permit Application 12/2021 <br />