Laserfiche WebLink
Dispersal Component:(Does not agp+h to Holding Tanks <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) Cells Flooded/Ponded <br /> 027 0 Lis-0 <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (System installed before 1/1/2000) r <br /> Sanitary SN stem Failure: (Mark correct response) <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES CT? <br /> r•" <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 Signature: MP/MPRS#: Business Phone Number. <br /> 1,(_).‘I lye ac . /0114 y Y 7/‘-‘CI . 9 <br /> Plumber's Address: City,State: Zip Code: <br /> N 2�(I�( J1lr�f tarp, t ,tiy� - 4,-._ 'r _Owl(( Like �.�.�y S11f8 71 <br /> Burnett County Office Use Only: <br /> Approved Fee Collected: DSPS Cred.No. Date Issued Issuin Agent Signature <br /> 0 Disapproved(Reason to be conveyed in v0 pJLJ <br /> writing) ���� �CJ�Q7� �Z 'J <br /> Conditions of Approval/Reasons for Disapproval: <br /> Other Comments: <br /> Page 2 of 2 <br /> Reconnect Permit Application 12/2022 <br />