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Burnett County Zoning Administration <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 744,0 County Road K,#102 ' a <br /> Siren,Wisconsin 54872 J �'---0O(715}9-2138 <br /> SYSTEM EVALUATION REPORT FO J ' <br /> NAME 20 <br /> ADDRESS �o <br /> FIRE #/ROAD NAME 4.4;z 5!L ay. 2z ded <br /> LEGAL DESCRIPTION Se-c, <br /> COMPUTER # <br /> - TANKS <br /> MFG ec e_ TYPE ST"SEL SIZE I cD 0 <br /> BAFFLE CONDITIONVlor,a. <br /> MANHOLE COVER COVITTN o� <br /> COMMENTS OWXA� �tr;fi c <br /> - DRAINFIELD/DRYWELL <br /> SIZE TOTAL SQUARE FEET <br /> SYSTEM ELEVATION awe sfrr�£D S.r Ac 7- &*-it <br /> BENCHMARK -. <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE _ YES/ <br /> DISCHARGING TO SURFACE YES/ <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YES/ <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 Y e`. Lic. # �S'fb�79 <br /> (plea .print) <br /> Signature Date 7 <br />