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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 SE 5LCRIEREMIRM <br /> ADDRESS 12.S4S +^ 81. N . HogIll Md -6514q7- <br /> FIRE <br /> 5 2FIRE #/ROAD NAME 2-9:Z020 o <br /> LEGAL DESCRIPTION LOT i C M VOL . I 2Z <br /> COMPUTER # <br /> - TANKS <br /> MFG TM C TYPE eF L- SIZE SIJ 40t. . <br /> BAFFLE CONDITION <br /> MANHOLE COVER CONDITION <br /> COMMENTS <br /> - DRAINFIELD/ <br /> SIZE IZX 20 TOTAL SQUARE FEET 24O <br /> SYSTEM ELEVATION 9 <br /> BENCHMARK Bo 0 ou £ i i <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE <br /> DISCHARGING TO SURFACE <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER O <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. V65 <br /> Name �1_ , PARD &991N-S Lic. #—:3-L70 <br /> (please print) //�� ,L /� <br /> Signature 4u" 11II IitlY- Date '7 - 6 - /S <br />