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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 &s2 ! 4 1f)r9N / t Lti S q Y c"7 <br /> FIRE #/ROAD NAME 76,Q 61, L72 5 ,e4-�4 -rT4rc- //"e 7 <br /> LEGAL DESCRIPTION - C-, 1111a A) %y $ -a9 7il/AV APIAm <br /> COMPUTER# e 3A 9V5-6—el —.3 r C� <br /> • TANKS / <br /> MFG A1`4- TYPE S7-&Z--Z- SIZE 7 Sr <br /> BAFFLE CONDITION e'K <br /> MANHOLE COVER CONDITION D <br /> COMMENTS <br /> • DRAINFIELD/DRYWELL <br /> SIZE z ' X 3c> TOTAL SQUARE FEET 3�� <br /> SYSTEM ELEVATION_ <br /> BENCHMARK f1L--ry T C +4 h) /t"C' E> " <br /> • IS SYSTEM: <br /> BACKING UP INTO STRUCTURE? YES OR4 <br /> DISCHARGING TO SURFACE? YES OR O <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES O NO <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 "n?o/-A A--Z) !�-7- -fkQFri License <br /> (Please print)n <br /> Signature Date l 9L U 3 <br />