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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division oLHealth No. 15650 <br /> FEE $1.00 P.O.Box 309 <br /> (I Permit per Tank) ' Madison,Wisconsin 53701 <br /> Date Issued <br /> Tank Size= gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. z This permit is for purchase of septic tank only and does (White)-Property Owner <br /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (glue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> eta Gaity I $amt. it <br />� Location(Legal Description) of Property Where Tank Will be Installed County <br /> SW SM 3111047 TM 8M Hnrlo�tt <br /> Plumber's Name License No. Address <br /> LIM DIIIIIII101i IP 33U sire at I1 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent(Town,Village,City) County <br /> *68two W1 5k" <br /> Title:: <br /> Signature <br /> a'w's+s �rll�ti�' <br />