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BURNETT COUNTY ZONING ADMINISTRATION <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 COUNTY ROAD K,#120 PHONE(715)349-2109 <br /> SIREN,WISCONSIN 54872 <br /> PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM EVALUATION FORM <br /> *Must be filed by a licensed WI Master Plumber* <br /> OWNER NAME C ; o` Be ) 101c, ? <br /> MAILING ADDRESS G ► 'c C d >rr e a L ? W Qdac 4n/ .C;La 93 <br /> SITE ADDRESS ) 1 <br /> LEGAL DESCRIPTION J� Y f 5 Lil g a ' j 3 % E ) W <br /> PIN# 0.7 - 01Z-c'_- 3 -- ) C - S- 3 Oz-0 0-023000 <br /> • HOLDING/SEPTIC TANK <br /> MANUFACTURERS ; t 6 MATERIAL Pe ))/ CAPACITYA; ( , <br /> BAFFLE CONDITION (2°o 1 <br /> MANHOLE COVE SER CONDITION C70 CP <br /> COMMENTS Tc\ ")n C, 0_1:1 yip') C d01 ;i- i o.r\ EP)57 2 N k,/ <br /> • DISPERSAL COMPONENT ��11/1 <br /> DIMENSIONS ) O't Lf rj MATERIAL G - F )C , v <br /> SYSTEM ELEVATION (IN RELATIORI TO SOIL BORING) <br /> BENCHMARK INFORMATION !VII <br /> COMMENTS S� e Yf 15 }- IDS' G pyec t( ✓� P ; frct '/-ic'ii <br /> 4. i ,b <br /> • SANITARY SYSTEM > c 4i r)r ,� i ,10 0;/de/ <br /> BACKING UP INTO STRUCTURE? YES-p) <br /> DISCHARGING TO GROUND SURFACE? YES- <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES -( <br /> • SOIL BORING VERIFICATION (CST Soil Report Required) <br /> • PLOT PLAN (Must provide plot plan showing location of existing septic tank, drainfield, well, lot <br /> lines and other related setbacks, as well as a benchmark.) Provide other comments below: <br /> Plumber Name PO\ ,� ,ss� C/L/ License# )0 7Z <br /> (Please print) <br /> Signature1()J-- Date \ 2 S 2 / <br /> Revised 11/4/2019 <br />