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Dispersal Component: (Does not a 1v to Holdin Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square F 7 ----- <br /> looded/Ponded <br /> 6� v� <br /> System Elevation in Relation to Soil Boring Benc mark I ormation <br /> (System installed before 1/l/2000) nj ill <br /> �b' )' <br /> Sanitary System Failure: (Mark correct response) <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES O <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 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) Plumb igna MP/MPRS#Tz: Business Phone Number: <br /> J� <br /> Plum er'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 14 150 <br /> writing) J <br /> Conditions of Approval/Reasons for Disapproval: <br /> Other Comments: <br /> Page 2 of 2 <br /> Reconnect Permit Application 12/2024 <br />