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DIF-(,CE J V FE <br /> luli APR � 4 2 � ETT COUNTY ZONING ADMINISTRATIO <br /> N <br /> Burnett County URNETT COUNTY GOVERNMENT CENTER <br /> Land Services Department <br /> 7410 COt'N IY ROAD K 0120 PHONE(71.4)349-2109 <br /> VUSC0\—SIN-4872 <br /> PRIVATE OrSITE 'WASTEWATER TREATMENT SYSTEM EVALUATION FORM <br /> ;Must be Med by a licensed WI Master Plumber <br /> OWNER NAME t S 't <br /> MAILI\iG ADDRESS ,2 S' <br /> SITE ADDRESS t t T b 19 3 <br /> LEGAL DESCRIPTION L,. c., z' <br /> PIN= 0.2 U 15-00 9 L(00 <br /> • HOLDING/SEPTIC TANK <br /> MANUFACTURER L /lc. T MATERIAL Cov1 C^c4, CAPACITY <br /> BAFFLE CONDITION <br /> ':NL•�NTHOLE COVER/RISER TTION C <br /> CON04ENTS Al 61 , <br /> • DISPERSAL COMPONENT <br /> DIMENSIONS f d X 3 0 _ MATERIAL 1\c` k (�c <br /> SYSTEM ELEVATION(IN RELATION SOIL BORING) -O <br /> BENCHMARK INFORMATION <br /> COS ear <br /> • SANITARY SYSTEM <br /> BACKING UP INTO STRUCTURE? YES <br /> DISCHARGING TO GROUND SURFACE? YES N <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES O <br /> SOIL BORING VERIFICATION(CST Soil Report Required) <br /> PLOT PLAN (Must provide plot plan showing location of existing septic tank, drainfield Fell, lot <br /> lines and other related setbacks, as well as a benchmark.)Provide other comments below: <br /> / 'j <br /> Plumber Name ` ` OV(�� License# g 1 L; �l <br /> (Please printl <br /> SgMature Date <br /> ReNls 1 1/4120 1 9 <br />