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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 NO <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 Signature: /� MP/MPRSW No.: Business Phone Number: <br /> ,e1 c.k /C kins /Z /,z4a/Z` of ots-es- 1 7/57_,5-g" y/-1. 7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> pi-77(vo 144—i 7r <br /> rv-45574e 8-S? <br /> Office Use Only: <br /> XApproved <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date Issued IssuingAgent Signature <br /> ❑Owner Given Reason for 0�Disapproval in Writing $1,�� �SIQ�i� � s 2ziko <br /> Comments: <br /> bk 4c 'MC-Ptak. -ka a 3 bed,rotrn 09 LA-04\ 9 f—► IAA.Th 2 • (tom 9a1. <br /> koic tn() Es <br /> Conditions of Approval/Reasons for Disapproval: <br /> RISel's rnuS- be aloot, .�1,o piGUn e/€v W <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />