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Dispersal Component: Does not apply to Holding Tanks <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) Cells Flooded/Ponded <br /> 3' x �0' Oz *) q40 s%iL <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (System installed before 1/1/2000) <br /> Sanitary System Failure: Mark correct response) <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES ,.-Z1CL-- <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES _Na- <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES <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 /> Plumber's Name(print) Plumber's Signature: MP/MPRS#: Business Phone Number: <br /> Plumber's Address: City,State: Zip Code: <br /> Burnett County Office Use Only: <br /> ❑Approved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> ❑Disapproved(Reason to be conveyed in <br /> writing) <br /> Conditions of Approval/Reasons for Disapproval: <br /> Other Comments: <br /> Page 2 of 2 <br /> Reconnect Permit Application 12/2024 <br />