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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 50 N �TQQZZ4J661Z <br /> ADDRESS 5155 MWEV, A LJc. MN• SSno <br /> FIRE #/ROAD NAME LAKES <br /> DJZ- <br /> LEGAL DESCRIPTION PAPIT OF LK Zo C04-DO UNTA <br /> COMPUTER # (73 SD DI <br /> - TANKS <br /> MFG WCP TYPE CONC- SIZE 12DO <br /> BAFFLE CONDITION <br /> MANHOLE COVER CONDITION OD <br /> COMMENTS <br /> - DRAINFIELD/DRYWELL <br /> SIZE 'X2 ' TOTAL SQUARE FEET Z[II Z <br /> SYSTEM ELEVATION <br /> BENCHMARK vair PIN <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE YES/NO 90 <br /> DISCHARGING TO SURFACE YES/NO 90 <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YES/NO Yp <br /> - SOIL BORING VERIFICATION (provide on CST Soil Report) <br /> - PLOT PLAN (must provide plot plan showing location of existing septic tank, <br /> drainfield, well, lot lines and other related setbacks. <br /> - If the existing system is undersized, indicate whether or not a replacement <br /> area is available. <br /> Name /S I C14A)ZO 4&LA Lic. # 2zs�51 <br /> (please print) <br /> Signature IF,"" "" Date 1-9- 11 <br />