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CONVENTIONAL IN -GROUND POWTS DESIGN <br />Residential Application <br />Index and Title Page <br />Owner's Name: /) E > J-o C- <br />Owner's Address: a A y2? � : 5 S <br />Site Address: ' 7o K 1 / <br />0 <br />Legal Description: A / &, L., r 5 2 3 7 `�� <br />Town: C k —5 e t J <br />County: BURN>ETT c/ <br />S�CSM: V / 6 / �` Lot No. Block No. <br />PIN: n '7 0 S/c9 ! 5� v?3 .3- 0 / 0 /dZ <:�a v <br />r <br />Plumber Name: <br />Plumber Address: <br />Telephone: <br />Signature: <br />Date: <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 />r <br />l <br />127_/? <br />