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Wisconsin Department of Industry, SAN RY PERMIT ounty <br /> Labor and Human Relations <br /> ransfer / Renewal Cn <br /> Safety and Buildings Division LB 67-T) Uniform Permit Number <br /> Bureau of Building Water Systems -�T' / , y i �(�(�� <br /> oh rti l�bt 6 1 _I <br /> 54 <br /> Personal Information you provide may be used for secondary purposes[Privacy Act s. 15.04 1 m . <br /> Permit Renewal Date Permit Transfer Date Original Permit Issuance Date State Plan ID Number <br /> -go--o <br /> Property Location r'% Town ❑Village ❑City of: <br /> 1/4 1/4,S 3V ,T 4D N,R I E o <br /> Lot Number Bloc umberivi ion Name Nea Road ake or Landmark <br /> 3 <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRED TO: <br /> Name(print) ignature Name(print) Phone Number <br /> Address hone Number Address <br /> 7 <br /> I,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> PlumbSignature/ ! XrouejAu—�b, <br /> us Plumber Name(if changed) <br /> PI berAddress QV Address <br /> MP/MP Number I Phone Number MP/MPKbW Number None Number <br /> 0,1314 113 is/- l� a <br /> Issuing Agent Signature Date Approved <br /> SBDW-6399(R.04/95) Distribution:Original-County; Copy-Bureau of Building Water Systems; Copy-Owner; Copy-plumber <br />