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Burnett County Zoning Administration <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 County Road K,#102 Phone(715)349.2138 <br /> Siren,Wisconsin 54872 <br /> SYSTEM EVALUATION REPORT FORM <br /> NAME 4 <br /> ADD S 5 Q R <br /> FIRE #/ROAD NAME S f/ R <br /> LEGAL DESCRIPTION A)f s' sEc 5' >' d S <br /> COMPUTER # <br /> - TANKS <br /> MFG t,JEBS7ER TYPE CONCRE (ZE 6 <br /> BAFFLE CONDITION <br /> MANHOLE COVER CO ITION D <br /> COMMENTS <br /> - DRAINFIELD/DRYWELL <br /> SIZE /') " X '0 7 TOTAL SQUARE F T <br /> SYSTEM ELEVATION 0 4j E /V / <br /> BENCHMARK <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURES/NOAk <br /> DISCHARGING TO SURFACE /NO U <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER ES/NO7_Q <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 a replacement <br /> area is available. <br /> Name CA) S7`14?Az3EL ic. #CS�AM 3SOD- <br /> (pleas <br /> Signatureate 6 <br />