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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 Sta N T�TNcti <br /> ADDRESS <br /> FIRE#/ROAD NAMEx 7 A as <br /> LEGAL DESCRIPTION JF sr J. 7N TKe v Rlto tv <br /> COMPUTER# 0.10 4100 0 3 ,7290 <br /> • TANKS <br /> MFG 7-m L TYPE Sf cc f SIZE 7fv <br /> BAFFLE CONDITION fw;e <br /> MANHOLE COVER CONDITION Fw;e <br /> COMMENTS -r&H k ?-a be Reo/we s.0 w:Fti w /OOM�(.Lb sw� cent. <br /> • DRAINFIELD/DRYWELL <br /> SIZE lee( TOTAL SQUARE FEET G00 <br /> SYSTEM ELEVATION 96• y <br /> BENCHMARK Too e vent �0r <br /> • IS SYSTEM: <br /> BACKING UP INTO STRUCTURE? YES OR <br /> DISCHARGING TO SURFACE? YES O <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES O <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 , )aw,rs S. Jw.,i e !s License# �4 73 Ufa O <br /> (Please print) <br /> Signature Date lo— q— 07 <br />