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CONVENTIONAL IN -GROUND POWTS DESIGN <br />Residential Application <br />Ind/ex and Title Page <br />Owner's Name: l.� mo=b r;4 A e-5 S <br />Owner's Address: _-Z3 0-0 A N 5o ,,j <br />CS r^ n <br />f— !2- w-77 to <br />Site Address: <br />Legal Description: �� �� N ��–�1 uJ .S� 37/.3ZA1,ef / 9 4-) <br />Town: �%, �'!�ft/�5 �.67A- Cl <br />County: BURNETT <br />Subdivision/CSM: — Lot No. --- Block No. <br />PIN: 0 % o yD ;z 391 !,F a 3 <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 />Signature: tl�, <br />Date: <br />