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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 <br /> ADDRESS t v Oji a-(-4) 'SyS d crty SD . <br /> FIRE #/ROAD NAME o C� <br /> LEGAL DESCRIPTION_ _ t/• S-ccs. 1 <br /> COMPUTER # <br /> - TANKS <br /> MFG % M. (d • �n TYPE STS _ SIZE 7� <br /> BAFFLE CONDITION GmmT� <br /> MANHOLE COVER CONDITION d5mC <br /> COMMENTS ouJ.vZ'7L- ur&VAJD 6W ,n4 %C W L=�v trCv1 <br /> - DRAINFIELD/DRYWELL <br /> SIZE !8 V23, TOTAL SQUARE FEET <br /> SYSTEM ELEVATION 97 - 6 <br /> BENCHMARK ?off n F �.C!Sr FeoT/ <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE YES/915) <br /> DISCHARGING TO SURFACE <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YES O <br /> OIL 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 /> NameDNA 1—(� .+ ( � Lic. # <br /> (pl t) <br /> Signature Date �� <br />