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Owner's Name <br />CONVENTIONAL IN -GROUND POWTS DESIGN <br />Residential Application <br />Index and Title age 45.e_ ^.-� _f� /� <br />Owner's Address: ?? 7 119Q <br />f <br />Site Address: <br />Legal Description: <br />Town: K <br />County: BURNETT t LK , <br />Subdivision/CSM: 141" � ( ! ` uM L S S4 Lot No. Block No,! <br />Plumber Name: <br />Plumber Address <br />Telephone: <br />Signature: <br />Date: <br />0`7 0,o 0 a 410 jd 3 - « 016 ol3�r�c� <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 />WADE RUFSHOLM Credential No. 227691 <br />P.O. Box 514, Siren, WI 54872 <br />715-349-7286 <br />'54" -18, <br />