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D' rsal Component:(Does not apply to Holding Tanks <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) Cells Flooded/Ponded <br /> 12, (qb) Nd5i & °�1G�r/GcYe - <br /> System Elevation in Relation to Soil Boring Benchmark information <br /> (System installed before I/]t2000) f /a' <br /> Sanitary System Failure: Mark correct response) <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 N <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 M: Business Phone Number: <br /> -71f <br /> �zl <br /> Phunbees Address: City,State: Zip Code: <br /> Burnett County Office Use Only: <br /> JKAppmved Fee Collected: DSPS Cred.No. Date Issued Is9uing Agent Signature <br /> ❑Disapproved(Reason to be conveyed in <br /> l� <br /> writing) �7�.�= �D�Y(^ t <br /> Conditions of Approval/Reasons for Disapproval: <br /> Mr- To Excce o Z <br /> Other Comments: <br /> Page 2 of 2 <br /> Reconnect Permit Application 12/2024 <br />