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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 lin 3-U NCI UW <br /> MAILING ADDRESS )(p IS V `= 1-0liVIO'j WI . 9+6 34 <br /> SITE ADDRESS ic04 MORrht st rz t'R.• Vick NBuin1 W 1 54VbSO <br /> LEGAL DESCRIPTION LoT Ti 4- 7g foy 12.Iv46 ADD 11D V.1/ <br /> PIN# 07-01-z-2-4o- IS- is- 5 15- 2-ic- og2000 <br /> • HOLDING/SEPTIC TANK <br /> MANUFACTURER W(',P MATERIAL (j c.- CAPACITY 7 S 0 <br /> BAFFLE CONDITION Ole <br /> MANHOLE COVER/RISER CONDITION Ole. <br /> COMMENTS <br /> • DISPERSAL COMPONENT <br /> DIMENSIONS I Z X yo/ TYPE &MATERIAL Aloc,re%7tc' <br /> SYSTEM ELEVATION (IN RELATION TO SOIL BORING) 95.0 <br /> BENCHMARK INFORMATION Tp [ 0v- f-wwo2 <br /> COMMENTS <br /> • SANITARY SYSTEM <br /> BACKING UP INTO STRUCTURE? YES <br /> DISCHARGING TO GROUND SURFACE? YES teLITR <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 ftic/Miti /IvpgiAfs License # Zzs$ <br /> (Please print) <br /> Signature T I Date <br /> Revised 11/4/2019 <br />