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Dispersal Component(Does not apply to Holdin Tanks) <br /> Dimensions(Square Fect) Total Dispersal Area(Square Feet) <br /> 5^X. 0 = 15 5�. I S. 7X 4Z;70 = ( / O9 <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/1/2000) <br /> /o ), 5 Top 0 u— I <br /> Sanitary System <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES NO J <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES NO <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES NO) <br /> Responsibility Statement: <br /> 1,the undersigned,assume responsibili for h PO TS activity for which this permit is issued. <br /> Plumber's Name(print) PI be s Sip at MP/MPRSW No.: Business Phone Number: <br /> D4C)11 a+r\ eFS 1/ 1Z 00 7 0 'g(> 71 S-399SS33 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Dat Issued Issuing Agent Signa e <br /> proved ❑Owner Given Reason for �j , <br /> Disapproval in Writing 150. Oo 1,181913 13 420 ;020? iMA)L,� <br /> Comments: <br /> APPROVED <br /> Conditions of Approval/Reasons for Disapproval: <br /> id Now propowt evioIw inAN, ol..11 be I bedroowt <br /> 1 t iftr vu usf be prt5(4A . <br /> Au V lea 04-cutaktet sr/chi/146 s hie twit ale 56°Q.Ck5 /14(4 + be v"f; <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />