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Dispersal Component(Does not apply to Holding Tanks) <br /> Dimensions(Square Feet)4e k ivinif (MX X 5'% Total Dispersal Area(Square Feet) <br /> 7-_-3,143)f-i-a IX 9- 6 <br /> System Elevation in Relation to Soil Boring Benchmark Information q/ [�� <br /> (ONLY for a system installed before 1/1/2000) S y 5 frp .p'eva/.e,'1 r j 3 P�S <br /> Srt) 6x1,` Rc `I c F.rte( Gr4e-e(?tiabo, R$•1tied <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 responsibility for the POWTS activity which this permit is issued. <br /> Plumber's Name(print) Plu er Signa re: , MP/MPRSW No.: Business Phone Number: <br /> f'cwl ide,J uE''i /03037v 7157-,205--40097 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> lV Lig ii yfUto .' tier 1.),%✓t 54/00 <br /> Office Use Only: <br /> 0 Disapproved ee Collected: DSPS Cred.No. Date Issuid suin Age Sign r <br /> Approved 0 Owner Given Reason for op �te Q OA/2m <br /> Disapproval in Writing 77J <br /> Comments: <br /> APPROVED <br /> Conditions of Approval/Reasons for Disapproval: <br /> Sepkc kids vmdst be heplaccd *t6 lett ch k added <br /> tgi *wt. iw+wk Au* I.c iK rot avudtt614. <br /> 4i*tit, rate to vim# 1.c p um+. <br /> S tc, 54 ref k 5carvietat lout, 1 /202.o. <br /> Revis 12/4/19 u f/ <br /> Page 2 of 2 <br />