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Dis ersal Component(Does not apply to Holdin Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> (pS0 <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/l/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 undersi ned,assume responsibility for the POWTS activity for which this ermit is issued. <br /> Plumber's Name(print) Plumber's Signature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> �7G o A4,r 3s— <br /> w�ss�� <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> Approved ❑Owner Given Reason for <br /> Disapproval in Writing l�IuI , <br /> Comments: <br /> 1���.ru� rw� -I�o kX.c eed 3 �roomS � sf}N-22- l38 <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />