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Dispersal Component(Does not apply to Holding Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> 8 X y1/Sf�nJ Rouiv€/ 3 76 1ST,./Aria o AW JC/ //5 7 <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/1/2000) <br /> &el <br /> PtvabON 7f 3 tioa%or,Ni EL 91gH 4% /,`N ifec //cw v°P veL4a'1 <br /> Sanitary System <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES NO <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES itif <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> Plumb 's Name(print) Plum Signature: MP/MPRSW No.: Business Phone Number: <br /> l©/ia C7 8S 1?5h' 7i5-6-ozo2 <br /> P umber's Address(Street,City,State,Zip Code): � r���8 �/rt�j <br /> 68 ' <br /> wed,/r w.- 62/13f, <br /> Office Use Only: <br /> 0 Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> XI Approved ❑Owner Given Reason for C dp G I_ I 2 <br /> Disapproval in Writing 4)1 J� 'J�W71 1 Z`/0023 f /i C) <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />