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Burnett County Zoning Administration <br /> B RNETT COUNTY GOVERNMENT CENTER <br /> 7410 County Road K,#102 Phone(715)349-2138 <br /> Siren,Wisconsin 54872 <br /> SY STEM EVALUATION REPORT FORM <br /> NAME T - <br /> ADDRESS ')1o7qD <br /> FIRE #/ROAD NAME <br /> LEGAL DESCRIPTION ` etre ATO <br /> COMPUTER # <br /> - TANKS <br /> MFG TYPE SIZE / 000 <br /> BAFFLE CONDITION U <br /> MANHOLE COVER CONDITI N o <br /> COMMENTS <br /> - DRAINFIELD/DRYWELL <br /> SIZE r s( �s TOTAL SQUARE FEET-260 '2 <br /> EET260a <br /> SYSTEM ELEVATION <br /> BENCHMARK <br /> A/o 1n/1-FTE/< <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE ANO NO <br /> DISCHARGING TO SURFACE YES/NO /a' D <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YA'S/NO Nb <br /> - SOIL BORING VERIFICATI E (provide on CST Soil Report) <br /> - PLOT PLAN (must provide plot plan showing location of existing septic tank, <br /> drainfeld, 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 Cf e iL -sC R Lic. # FJ 1,2 <br /> (please print) a o S y o <br /> �p,ps <br /> � `� � <br /> Signature Date <br />