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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 /> 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 <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> Plumber's Name(print) Plumber's Signatur : MP/MPRSW No.: Business Phone Number: <br /> /?i c(C #0? ( �/4 ,-kS-i <br /> �-� �d� his <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> 0 Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> ttX Approved ❑Owner Given Reason for S �I,�j p <br /> /74 Disapproval in Writing ��� � I J''1 f 202y '�U�/" "� <br /> Comments: <br /> ParDSe d bw+l dn 'ts 12-e..r m.1 I-kd -b b-e. a Cl,ti...e e,la .see. LLL P -2 q -283 <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />