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Burnett County Zoning Administration <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 County Road K,#102 Phone(715)349-2.1Z8 <br /> Siren,Wisconsin 54872 -_ 'h <br /> SYSTEM EVALUATION REPORT FORM `& N N <br /> r. <br /> NAME S�RR <br /> ADDRESS D. w6as7gg w1l S-V9,73 <br /> FIRE #/ROAD NAME . D. <br /> LEGAL DESCRIPTION <br /> COMPUTER # <br /> - TANKS <br /> MFG W CP TYPE CQ N- SIZE_]A <br /> BAFFLE CONDITION ODR <br /> MANHOLE COVER CONDITION GOOD <br /> COMMENTS <br /> - DRAINFIELD/DRYWELL <br /> SIZE 17—Y, 20 TOTAL SQUARE FEET 7— <br /> SYSTEM ELEVATION <br /> BENCHMARK IDe Of pipe <br /> - IS SYSTEM: <br /> BACKING UP INTO STRUCTURE YES <br /> DISCHARGING TO SURFACE YES <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER Y /NO <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. y CS <br /> Name K161199P LbPkIA15 Lic. # 367 0 <br /> (please print) <br /> Signature Date_ �� <br />