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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 548 2 <br /> SYSTEM EVALUATIOiV REPORT FORM <br /> NAME .— <br /> ADDRESS 9/0 ZLV 2 e6ffCP Z i • <br /> FIRE #/ROAD NA qE <br /> LEGAL DESCRIPTION-11- // _ -36 - O <br /> COMPUTER # - 6 - <br /> - TANKS 1 <br /> MFG a TYPE <br /> C'1 &- _ SIZE �� ���,i <br /> BAFFLE CUNDTTION - <br /> MANHOLE COVER CONDITION--. <br /> COMMENTS _ - -- - <br /> - DRAINFIELD/D Y)X'ELL <br /> SIZE TOTAL; SQUARE FEET_ \ _ <br /> SYSTE LEV&T ON <br /> BENCHMARK -- <br /> - IS SYSTEM: <br /> BACKING UP O STRUCTURE YESINO <br /> DISCHARGING TO SURFACE YES/NO_ <br /> DISCHARGING-TO GROUNDWATER OR SURRA :E WATER YES/NO <br /> - SOIL B RING ERIFI ATION (provide on CST Soil Report) <br /> - PLOT PLAN (must provide plot plan stowing location of existing septic tank, <br /> drainfield, well, lot lines and other related setback;. <br /> - If the exis ing system is undersized, indicate whether or not a replacement <br /> area is available. <br /> l <br /> l Tom— C Ll <br /> Name —. <br /> 1 rint) <br /> Signature - Date <br /> 7 � Se, Ui�L <br />