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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 /0 is Johnsen <br /> ADDRESS .010 y /";u <br /> FIRE #/ROAD NAME A7 s36 6..y 4k Ad. <br /> LEGAL DESCRIPTION Mw % Nrv',4 s, 8 r aoV /?/q W <br /> COMPUTER # ad 8 - 40,09 <br /> - TANKS <br /> MFG W. C. P 400941/ TYPE Gas7cr�er`e SIZE I o0 al <br /> BAFFLE CONDITION d.•d <br /> MANHOLE COVER CONDITION e-sed <br /> COMMENTS <br /> - RAINFIELD DRYWELL <br /> SIZE 0-x d-X TOTAL SQUARE FEET oI G q <br /> SYSTEM ELEVATION 9 F• 9 <br /> BENCHMARK n w / i n /y" 4.µb!e <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE YES/ O <br /> DISCHARGING TO SURFACE YES O <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YES N <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— JM-rn 6�s S. O'glyle-6 Lic. # 1.73 qA 0 <br /> (please print) <br /> Signature ` S 1/aLvut�s Date <br />