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Burnett County Zoning Administration <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 County Road K,#102 Phone(715)3492138 <br /> Siren,Wisconsin 54872 <br /> SYSTEM EVALUATION REPORT FORM <br /> NAME �� JPP 1' 00-&L <br /> ADDRESS Al 'Sr-' <br /> FIRE #/ROAD NAIdg S*? COU <br /> LEGAL DESC ON i <br /> COMPUTER # <br /> - TANKS <br /> MFG 1066 s-r6 K CLIA)CRErt TYPE CO A) C R E SIZE Zsd . <br /> BAFFLE CONDITION 600P <br /> MANHOLE CO CONDITION rQab <br /> COMMENTS <br /> DRAINFIELD/DRYWELL <br /> S STEM ELEVATION TOTAL4 S�UAZ2E J�T <br /> BENCHMARK F-4/777 <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE YES/NO <br /> DISCHARGING TO SURFACE YES/NO <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER YES/NO <br /> - SOIL B (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. SEE CS7 <br /> RE?PoR)F-- <br /> - If the exis g system is undersized, indicate whether or not a replacement <br /> area is available L07--5- or l'doM FOK <br /> � RrP�f3cFM,E�r/7` ,lRE'4 <br /> NameE 4 SITAM <br /> M L. Lic. # S 7`/�J 33 2_ <br /> (please pTint) <br /> Signature Date__:: <br />