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Owner's Name: <br />Owner's Address: <br />Site Address: <br />]Legal Description: <br />'own: <br />CONVENTIONAL IN -GROUND POWTS DESIGN <br />Residential Application <br />Index and 'Title Page <br />t <br />'M i k4 �i5hC_r <br />/_/C, <br />Z) �e r- &.,)...Z7- yg 1 3 <br />ggg7 L.� <br />County: BURNIET'T <br />n/CSM: V % p v7 Lot No. � block No. <br />IH <br />Plumber Name: <br />Plumber Address <br />Telephone: <br />Signature: <br />07 o19 A 3y & .33 571.�'�y6 olt ©00 <br />Page Index <br />Page 1 Index and Title <br />Page 2 Plot flan (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 <br />P.O. Box 514, Siren, WI 54872 <br />715-349-7286 <br />Date: 6 —� y -1 y <br />Credential No. 227691 <br />