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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 /> r�30 -Oj03 <br /> NAME G N <br /> ADDRESS <br /> FIRE #/ROAD NAME 75 , <br /> LEGAL DESCRIPTION -5- <br /> COMPUTER <br /> -COMPUTER # O D O - O <br /> - TANKS <br /> MFG _N-ATYPE SIZE <br /> BAFFLE CONDITION— , <br /> MANHOLE COVER CONDITION <br /> COMMENTS <br /> - DRAINFIELD/DRYWELL <br /> SIZE G TOTAL SQUARE FEET ,$ // <br /> SYSTEM ELEVA ON <br /> BENCHMARK _ <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE YES Nd <br /> DISCHARGING TO SURFACE YES <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YES <br /> i[1 <br /> - - SOIL BORING VERIFICATION (provide on CST Soil Report) <br /> PLOT PLAN (must provide plot plan showing location of existing septic tank, <br /> dr afield, well, lot lines and other related setbacks. S <br /> If the existing system is undersized, indicate whether or not a replacement <br /> area is available. U -';t4� L'& R-X <br /> Name �2 !/t ` v`/7 Lic. # <br /> (pleas print) . <br /> Date ` S-- CC <br /> Signature <br />