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Dispersal Component(Does not apply to Holding Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> (Z) 6x50 CeCw4�s ZZ ?0 4,0asQ.FT. <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/1/2000) <br /> 411"61M. 0. 6nAtt. I " Asp (Cetyt, L) <br /> Sanitary System <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? 0111. )Ne <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? IMO <br /> �/ <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? NNWy` <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibility for the POWTS,,ctivity for which this permit is issued. <br /> Plumber's Name(print) Plumber's Signature- MP/MPR� S Flo.: Business Phone Number: <br /> �' w�o f �,S(r,k L M&K SEPTIC & EXCAVATION <br /> Plum er's Addresss treet,City,State,Zip Code): , E16228-courrtntROAD <br /> SPOONER, WI 54801 <br /> 715-635-7482 <br /> Office Use Only: <br /> 0 Disapproved lee Collected: DSPS Cred.No. Da Its m Agent Signa <br /> pproved 0 Owner Given Reason for 4 p 1. <br /> t✓✓✓VV/ Disapproval in Writing 160.00 f is/ 7✓ 020 <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval:� <br /> N <br /> 1/ ett DA. Sawex ci i[ NOS- Seasoi Q4 sfruot PG, <br /> bc1 Ihs St etµ wtusf hate 'atter s nock t 0411,4 at atAv siaukoks above $re,w+d. <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />