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Dispersal Component(Does not apply to Holding Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/1/2000) <br /> m///'r1 R 2'�04 k- <br /> Sanitary System <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES 425 <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> Plumb s Name(print) J Plumb Signature: MP/MPRSW No.: Business Phone Number: <br /> er <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> 0 Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing gent Si ture <br /> ,(Approved ❑Owner Given Reason for p� t - 2 , <br /> Disapproval in Writing 5(5 0 17�77�.5 6/1/23 v • <br /> (� Q <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />