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Dispersal Component: es not applv to Holding Tanks <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) Cells Flooded/Ponded <br /> a _ 3 1 A YW yy ND 0 <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (System installed before 11/2000) <br /> N� f <br /> Sanitary Svstem Failure: ark correct response) <br /> SEPTIC SYSTEM BACKING UP/DISCIIARGING INTO STRUCTURE? YES NO <br /> SEPTIC SYSTEM DISCIL-kRGING TO GROUND SURFACE? YES NO <br /> SEPTIC SYSTEM DISCHARGP_VG TO GROUNDWATER OR SURFACE WATER? ITS 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 /> Plumbers Name(print) Plumber Signature: 1:;S <br /> RS Y: Business Phone Number:Mpf u1GRRD �1,s 7�a -09 <br /> Plumber's Address: City.State: Zip Code: <br /> ?`t 3 o ' LIE tA-4-z: Syoo <br /> Burnett County Office Use Only: <br /> Approved Fee Collected: DSPS Cred.No. Date Issued Mssuingt Signature <br /> ❑Disapproved(Reason to be conveyed in <br /> writing) <br /> Conditions of Approval/Reasons for Disapproval: <br /> btvtw'a� n64 4-0 �y-c-etj 2 4Qe ,rD)ms <br /> Other Comments: <br /> Page 2 of 2 <br /> Reconnect Permit Application 11/2024 <br />