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Owner's Name: <br />Owner's Address: <br />Site Address: <br />Legal Description <br />Town: <br />County: <br />CONVENTIONAL. IN -GROUND POWTS DESIGN <br />Residential Application <br />Index and Title Page <br />1s eA <br />e <br />rr ✓ C. <br />WXr_ 3 <br />.s /Z 77010 R 17 t.J <br />4,-J <br />BURNETT <br />Subdivision/CSM: Lot No. Block No. <br />PIN: o7 ©o (z 3S /% /� bot ©o� ©/l©oc- <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 RUFSJHOLM Credential No. 227691 <br />Plumber Address: P.O. Box 514, Siren, WI 54872 <br />Telephone: 715-349-7286 <br />Signature: e�/ <br />Date: <br />