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CCNVFNTH[ONAL lIN-GR UND POWTS IESIGN <br /> 'esidential Application <br /> ',raider and Title Page <br /> Owner's s Nane: 1 €I �f Pe ( Cc <br /> Owner's Address: 6 Sa / ,..?De7 ,4 VV <br /> 6-0/11 .e.rS� u)j 5- et <br /> Site Address: 4/60.? 05,n o r <br /> egalDescription: s y T 3g/Jif is-4) <br /> Town: L A-Po it ate <br /> County: B U R NI I TT <br /> Subdi @rision/CSM: Lot No. 6 Block No. — <br /> PI : 07 0/S/ a 3$ iS o 5/ 57/5— /29 a/64:7ov <br /> Page Index <br /> Page 1 Index and Title <br /> Page 2 Plot Plan(may include septic tank and filter specs) <br /> Page 3 Distribution Cell(s) Cross Section <br /> Page 4 Maintenance,Management and Contingency Plans <br /> Plumber Name: WADE RUFSHOLM Credential No. 227691 <br /> Plumber Address: P.O. Box 514, Siren, WI 54872 <br /> Telephone: 715-349-7286 ^ <br /> W <br /> Signature: j� „ e/" <br /> Date: 3 v-2y <br />