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CONVENTIONAL IN -GROUND POWTS DESIGN <br />Residential Application <br />Index and Title Page <br />Owner's Name: �Jv A' AW�' `7 <br />Owner's Address: l s 1 `'/ -5 fQ d d d r 4 A V e - <br />Site Address: <br />Legal Description: 0 C_ / G• , L. Y S 2 y ;�:�CJ AJ A / Y W <br />Town: .s e- 0 <br />County: BURNETT J <br />/CSM: 1%/S P / � Lot No.___L_Block No. <br />PIN: L7 C 2 2 416 l `/ a y D 0 3(�©ne; <br />Page Index <br />Plumber Name: <br />Plumber Address <br />Telephone: <br />Signature: <br />Date: <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 />