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BURNETT COUNTY ZONING ADMINISTRATION <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 COUNTY ROAD K,#120 PHONE(715)349-2109 <br /> SIREN,WISCONSIN 54872 <br /> PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM EVALUATION FORM <br /> *Must be filed by a licensed WI Master Plumber* <br /> OWNER NAME R..31--/-)E I I SIS -Fe r <br /> MAILING ADDRESS '21-17tdArm 6pr645S 5e3 7) 2_ <br /> SITE ADDRESS Li / ZS 2, 'Kd C <br /> LEGAL DESCRIPTION n tp T Lj o N R j S tk <br /> PIN# 67- ova-2- YO--15-Ito-5 o5-oo'- - 011000 <br /> • HOLDING/SEPTIC TANK <br /> MANUFACTURER sic MATERIAL CO h . CAPACITY I 71" <br /> BAFFLE CONDITION G.. ,t <br /> MANHOLE COVER/RISER CONDITION G a o .l <br /> COMMENTS <br /> • DISPERSAL COMPONENT <br /> DIMENSIONS 6 gi g _TYPE&MATERIAL v'/1ev- i) •f,{ 2 to 4/4 <br /> SYSTEM ELEVATION (IN RELATION TO SOIL BORING) 9o, <br /> BENCHMARK INFORMATION TA, , G e nT <br /> COMMENTS <br /> • SANITARY SYSTEM <br /> BACKING UP INTO STRUCTURE? YES-(IO2 <br /> DISCHARGING TO GROUND SURFACE? YES- <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES- <br /> • SOIL BORING VERIFICATION (CST Soil Report Required) <br /> • PLOT PLAN (Must provide plot plan showing location of existing septic tank, drainfield, well, lot <br /> lines and other related setbacks, as well as a benchmark.)Provide other comments below: <br /> Plumber Name JA S License# 73'/d v <br /> (Please print) <br /> Signature gr,v14A,J ADate •5--- / <br /> Revised 11/4/2019 <br />