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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 buyer Grhgrr Westbrook Z ownee 61',ey c%,•K <br /> ADDRESS 7ut Q4lors� W�/eM,w4 Mn'61SO4A /7e0 4Aket';11s Mjy sro yH <br /> FIRE#/ROAD NAME )y gS! Aytw r4,*., <br /> LEGAL DESCRIPTION X..3s "?,v R Ile <br /> COMPUTER# 39-/4- 3s y 03 - ooO- 011060 <br /> • TANKS <br /> MFG 7-/»C TYPE .ffe< I SIZE -7.f0 Sal <br /> BAFFLE CONDITION Ge0,4 <br /> MANHOLE COVER CONDITION Ga ed <br /> COMMENTS <br /> • DRAINFIELD/DRYWELL <br /> SIZE 1.11x Sb " TOTAL SQUARE FEET 00/ <br /> SYSTEM ELEVATION 97•I <br /> BENCHMARK /oo.o oP o F v eh-f- <br /> • IS SYSTEM: <br /> BACKING UP INTO STRUCTURE? YES OR <br /> DISCHARGING TO SURFACE? YES OR <br /> DISCHARGING TO GROUNDWATER OR SURFACE WATER? YES OR <br /> • SOIL BORING VERIFICATION(Provide on CST Soil Report) <br /> • PLOT PLAN (must provide plot plan showing location of existing septic tank, drainfield, well, lot <br /> lines and other related setbacks <br /> • If the existing system is undersized, indicate whether or not a replacement area is available <br /> Name ,Ji-w,,e j � da h(e is License# <br /> (Please print) /� <br /> Signature duyy .S /0G —Date-7— /9 v old <br />