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Dispersal Component(Does not apply to Ifolding Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> eiCO <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 NO <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES NO <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 /> 3r ai l 5�1�' o5m �� I Iq ON9 7,c S53-s&)9 <br /> Plumber's Address(Street,City,State,Zip Code). <br /> 9811 Q004' \-cee,V LucK 6,,,y 5-5 <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> )(Approved El Owner Given Reason for 1`v0 '�64-�I Le 11Z4202y <br /> Disapproval in Writing I OiddrititiVipe—D <br /> Comments: <br /> Connecfi II) garct VA:1 '1 124-41► +C exiS <br /> Conditions of Approval/Reasons for Disapproval: <br /> gIlow c (CarliY Q7Ct soak rew re, .1fs <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />