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/11/Dispersal Component(Does not apply to Holdin_ Tanks) 4,,L, adided.. <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <br /> T <br /> System Elevation in Relation to Soil Boring Benchmark Information <br /> (ONLY for a system installed before 1/1/2000) <br /> Sanitary System <br /> SEPTIC SYSTEM BACKING UP/DISCHARGING INTO STRUCTURE? YES NO <br /> SEPTIC SYSTEM DISCHARGING TO GROUND SURFACE? YES CgD <br /> SEPTIC SYSTEM DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES 'a <br /> Responsibility Statement: <br /> I,the undersigned,assume responsibili for the POWTS activity for which thismtt is issued. <br /> Plumber's Name(print) Plumber's Signature: (1•=.J".'RSW No.: Business Phone Number: <br /> 1Fga it Sc/0-ei, 4,--- .1,1 ��� ?�%7/Plumbers Address(Street,City,State,Zip Code)1 : 42 <br /> w,FC,6 s I--� /?d 5iov :—, c...J� 65'x/ <br /> Office Use Only: <br /> 0 Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Sign ur <br /> pproved 0 Owner Given Reason for i'� i . n <br /> Disapproval in Writing 145 1470.3 8/34,620 GJ �µµ`/ <br /> Comments: O <br /> APPROVED <br /> Conditions of Approval/Reasons for Disapproval: <br /> K Ttifie. rtUAICI reFfIc., Qter , YKrwHelt C•velgisnr $1444 41 bt 114. real "I^Whiatx <br /> 41KcA4- F6CV. w.14+ lot pita'. <br /> 4. r wows. shed h moos; shah. n LowteQ Use Rfm4;4. is 44,4. <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />