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Dispersal Component(Does not apply to Holdin Tanks) <br /> Dimensions(Square Feet) Total Dispersal Area(Square Feet) <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 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 for which this permit is issued. <br /> Plumber's Name(print) I Plumber's Signature: MP/MPRSW No.: Business Phone Number: <br /> &/4 � 1 ( 4G��> z Z7 ? I <br /> Plumber's Address(Street,City,State,Zip Code): <br /> /'e,< J G-�-ice � ' 7:2 <br /> Office Use Only: <br /> ❑Disapproved Fee Collected: DSPS Cred.No. Date Issued Issuing Agent Signature <br /> E Approved ❑Owner Given Reason for <br /> Disapproval in Writing <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 12/4/19 <br /> Page 2 of 2 <br />