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BURNETT COUNTY ZONING ADMINISTRATION <br /> BURNETT GOUTY (fib WNT CENTER <br /> 7410 COUNTY ROAD K,#102 I , J I f PHONE(715)349-2138 <br /> SIREN,WISCONSIN 54872 I SEP 0 2ta k <br /> 1.11 <br /> Burnett County <br /> t_and Services Department <br /> SYSTE14 EVALUAT16N REPORT FORM <br /> NAME rr<•n< oil /c4spe <br /> ADDRESS )S)5). 5>1),.h L<., ry /,., 575-9'i5 <br /> FIRE#/ROAD NAME Y o 7 C. iZ <br /> LEGAL DESCRIPTION S. A r Tie ry R /I<iv ( , /"-t- � <br /> COMPUTER# -7 ,-o - y0-I6 -oi. -5" - SUS — 2/7ec'o <br /> • TANKS <br /> MFG TYPE Go,,c SIZE <br /> BAFFLE CONDITION C 00 d <br /> MANHOLE COVER CONDITION 6 0ci <br /> COMMENTS <br /> • DRAINFIELD/DRYWELL <br /> SIZE ), 6 ' Y. ,).0 ' TOTAL SQUARE FEET /OcO <br /> SYSTEM ELEVATION 9 6, <br /> BENCHMARK To pet I/-r-rr )J ,p e (iJ I < „ t� =/e,/> <br /> • IS SYSTEM: <br /> BACKING UP INTO STRUCTURE? YES O' N• <br /> DISCHARGING TO SURFACE? YES OR e�� <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES O'!0 <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 it im e s l ! ii ' �� License# )7]9) C) <br /> (Please print) <br /> Signature J Date 8- - 1- 7) <br />