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BURNETT COUNTY ZONING ADMINI` '' ° ENS <br /> BURNETT COUNTY GOVERNMENT C � '' <br /> 7410 COUNTY ROAD K,#1021- <br /> (+ 3Z9- 12Q22 <br /> SIREN,WISCONSIN 54872 <br /> Burnett County <br /> Lend Services Department <br /> SYSTEM EVALUATION REPORT FORM <br /> NAME Ru v' Crrrger Inlestbroo/ J dLvnee Grry G/a..K <br /> ADDRESS icni BaylorA- 6./1/60. tvw 5":109d, / /7e9 //e&(t*i Or. LA/ ,.11e /Y1111 ,T.rt7 ' 1 <br /> FIRE #/ROAD NAME , 'jt ,Veit. n'1o." Or;oe <br /> LEGAL DESCRIPTION S.Ys T.794, !?/4 w <br /> COMPUTER# 07- e•/ 39-/G- 35-- y 03 - 000.. 011060 <br /> • TANKS <br /> MFG T/I C TYPE Jf e< I SIZE "Aro 94,/. <br /> BAFFLE CONDITION Geed <br /> MANHOLE COVER CONDITION Ceed <br /> COMMENTS <br /> • DRAINFIELD/DRYWELL <br /> SIZE 41 'x 3-6 TOTAL SQUARE FEET (oo/ <br /> SYSTEM ELEVATION 97./ <br /> BENCHMARK /do-o io, o f -t- <br /> • <br /> • IS SYSTEM: <br /> BACKING UP INTO STRUCTURE? YES OR g <br /> DISCHARGING TO SURFACE? YES OR ST <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES OR ei <br /> • SOIL BORING VERIFICATION(Provide on CST Soil Report) <br /> • PLOT PLAN (must provide plot plan showing location of existing septic tank, drainfield, well, lot <br /> lines and other related setbacks <br /> • If the existing system is undersized, indicate whether or not a replacement area is available <br /> Name ✓i. 'ef S der h r e lr License# J 7Y'7I4' <br /> (Please print) <br /> Signature )14,1,16, .S" Date 7— /9 v d d <br />