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Dispersal Component(Does not apply to HoldingTanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> I Lb C22 6 <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/1/2000) <br /> r-O0 <br /> Sanitary System <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 NO <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibilit for th POW' acti ty for which this permit is issued. <br /> PI tuber's Name n t) [Plumh'rs Signa r : MP/MPRSW No.: Business Phone Number: <br /> � �cs� ez ��� 2/S''�/-i' 8, <br /> Plumbers Address(Street,City,State,Zip Code): <br /> Jackson Plumbing <br /> 9306 Black Iztrrick Rood <br /> Webster,WI 54893 <br /> Office Use Only: <br /> 0 Disapproved 1Fee Collected: DSPS Cred.No. Da Iss ed mg gent Sign ure <br /> roved 0 Owner Given Reason for 160.00 10 ft3 4 00Disapproval in Writing 7 /z <br /> Comments: <br /> * *s+ OAlock ; ekaiK per ptu Aers CAMAIMtiojr. <br /> * RICK CPA propetf10 liAMO be• 3O f- ANA. %OlVlaIttleit. <br /> L4ovt 6'I aft off' VOuvCS •. tug.) stilt.", Wil( lot retai✓ecQ. <br /> Conditions of Approval/Reasons for Disapproval: <br /> AppRoviD <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />