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BURNETT COUNTY ZONING ADMINISTRATION <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 COUNTY ROAD E:,#102 PHONE(715)349-2138 <br /> SIREN,WISCONSIN 54872 <br /> SYSTEM EVALUATION REPORT FORM <br /> NAME 7�-, ,//.gFa <br /> ADDRESS 97o 4%k,a tusah /!p//s D. CHKnhas.trn MA/ 5'S317 <br /> FIRE #/ROAD NAME 17,y-/ 14 �. „rt /20e. <br /> LEGAL DESCRIPTION S. 3 k 7- 4'&A) R is—w <br /> COMPUTER# a-7 o/d 1lgy /6` 3k So.s- oe/ 6/9oe0 <br /> • TANKS <br /> MFG W- C . R TYPE SIZE /3 ao <br /> BAFFLE CONDITION 60 , z <br /> MANHOLE COVER CONDITION Ge,cP <br /> COMMENTS <br /> • DRAINFIELD/DRYWELL <br /> SIZE 14'.f 3y 0420 ke&Wt)TOTAL SQUARE FEET (2¢0 Per Peyw;c) _ <br /> SYSTEM ELEVATION • IF/. '/ <br /> BENCHMARK n a;l;� 04* ec <br /> • IS SYSTEM: <br /> BACKING UP INTO STRUCTURE? YES OR <br /> DISCHARGING TO SURFACE? YES ORaa <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES OR(gP <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 /> z.a [S 0u"1411S nn / <br /> Name ,s 0G"*S License# <br /> (Please print) <br /> Signature 4,,,__S'�� Date 16 3- I l <br />