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PLB. 68 a.. DEPARTMENT OF HEALTH AND SOCIAL SERVICES ry .� <br /> Division of Nlsalth 1 5 2 1.2 <br /> FEE $1.00 P.O.Box 309 NO <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued t/� 1. 7S <br /> Tank Size/ZCASigal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. . This permit is for purchase of septic tank only and does (White)-Property Owner <br /> (Pink)-TankRetailer <br /> not exempt installation from state or local approval D <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's <br /> c }- Owner's Addresss, ^� <br /> ko Le t \ . 'A 1.-1 r ,t . $t_ ¢ (')S t 1/4. it (-4 1 k `'ti t <br /> Location (Legal Description) of Property Where Tank Will be Installed r County <br /> t a <br /> N E c fit 6- 4 t 1-7) r wry sit N /•<' (c, LILA.V t.t CL 1"t-'-"- <br /> Plumber's Name License No. Address <br /> ec,,, \ t5. 5 UcA. SE ic--- 4v ‘. ? 13( Z 1 tt,. e isle i ( ...`kc. <br /> Signature of Person Obtaining Permit Address if Other Than Owner ► <br /> -7.4.-6-i 1Ghv n t1.: k...:7` O. ()10' ..-t , (.,, .- tI�j`-c V' Lc..)%. s , <br /> Address of Issuing Agent (Town, Village,City) i " County. <br /> A * i <br /> r. / /r; / /_ (; .(,;} .,� -,''s 1 ,4-.2'1////,'„.,'' /1/ <br /> Title: Signature <br /> o <br /> r,. � f T f s{ �fl r_j. )111:- <br /> , / -,, <br /> ./1 Ij <br />