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CI J3 <br /> Burnett County Zoning Administration <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 County Road K,#102 Phon (715)349.2138 <br /> Siren,Wisconsin 54872 SYSTEM EVALUAnON RE= FORM <br /> NAME n not bom <br /> ADDRESS r-4 r cr <br /> FIRE #/ROAD NAMEr Co c, lea <br /> LEGAL DESCRIPTION o <br /> COMPUTER k <br /> - TANKS // <br /> MFG Yr C6CM n4-' TYPE—S4S <br /> BAFFLE CONDITION o 0 <br /> MANHOLE COV.F,R C NDIPON <br /> COMMENTS 1 r <br /> - D AINFIEr. /DR dry we,11 rS C / <br /> SIZE 671/Q4 T a u TOTAL SQUARE FEET—/,f:>5 <br /> SYSTEM ELEVATION <br /> BENCHMARK N �✓ r r.e r`o iv o <br /> = oo ' <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE ITS <br /> DISCHARGING TO SURFACE -- <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER -IESf <br /> SOIL BORING VERIFICATION (provide on CST Soil Report) <br /> - PLOT PLAN (must provide plot plan showing location of existing septic tank, <br /> drainfield, well, lot lines and other related setbacks. <br /> If the existing system is undersized, indicate whether or not replacement <br /> area is available. t'Ae(fi S €✓«�+�j A rip ✓ A / Ic+CO- n� <br /> Name M/ 4t)e, /V (4T7' Ij�'c. # <br /> (please print) <br /> Signature /r�J <br /> abateg;�/(0 95 <br />