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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 /> 5x3-2' i-fzq <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (System installed before 1/1/2000) <br /> sNd e levy fic`dvt = Ci S t l ' i q `� S�stem Top 0 CASAAC\, � a cA� t!^ n�tNx.A. Se <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 (NOD <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'gnature: MP/MPRS#: Business Phone Number: <br /> Line TIAKt ts n k237,40 7 1 c--K(0 3- <br /> Plumber's Address: City,State: Zip Code: <br /> 330 .I Ate, G uLT S- (-fgT0 <br /> Burnett County Office Use Only: <br /> ,'Approved Fee ColOed: DSPS Cred.No. Date Issued Issuin ent Si at <br /> ❑Disapproved(Reason to be conveyed in )50_' ;J G�7 1/f'I 1 3 <br /> writing) �/ <br /> end ions of Approval easons for n / 1 <br /> Gtf ,A1,01 1 e Carl not Ib e v54 hK Q�714 <br /> unless a ne � 5 Sy i5 i45/ifec of e-t‘sfiy ps* ? <br /> (to S it Covvi t 5-�u,{e r� <br /> Other Comments: l/ <br /> Pb4- -� e ,e-e j a- b eds" - or y cc(tA 2 . <br /> Page 2 of 2 <br /> Reconnect Permit Application 12/2022 <br />