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Wisconsin Department of Industry, SANITARY PERMIT Cou t <br /> Labor and Human Relations <br /> TransfeBU <br /> r Renewal <br /> Safety and Buildings Division LB 67-T) Uniform Permit Number <br /> Bureau of Building Water Systems � ( / Wever- 3 <br /> Personal Information you provide may be used for secondary urRoses[Privacy Act s. 15.04 1 m . <br /> Permit Renewal Date Perm' Transfer Date Original Permit Issuance Date State Plan ID Number <br /> Property Location XTown ❑Village ❑City of: <br /> E 1/4 SE 1/4,S T N,R I E(or <br /> Lot Number Block Number SubdivisTon Name Nearest Road, Lake or Landmark <br /> Out <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRED TO: <br /> Name(print) Signature Name(print) Phone Number <br /> Address I Phone Num er Address <br /> I,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> Plumbe <br /> Aignature Previous Plumber Name(if changed <br /> PlumberAddresv PreviousPlumber Address <br /> P p�Prw; 5W6 �) 8gg l <br /> MP/MPR5W Number mone Number MP/M W......... I Phone umber <br /> J96 9L;91&0 7/5635--q&Q <br /> Issuing Agent Signature Date Approved q'S <br /> SBDW-6399(R.04/95) Distribution:Original-County; Copy-Bureau of Building Water Systems; Copy-Owner; Copy-plumber <br />