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PLB. •68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health <br /> FEE $10.00 P.O.Box 309 NO. 1173J"t 9 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 ` <br /> Date Issued 9/26/79 <br /> Tank Size 750 gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. X This permit is for purchase of septic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> (Blue)-Division <br /> Health <br /> Public and/or permits. (Canary))-issuing Agent <br /> Owner's Name Owner's Address <br /> Charles Lunde 1 31315 Evergreens Plymouth, N-N 55441 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> N NE S=04 13 T40' P15W Burnett <br /> Plumber's Name License No. Address <br /> Pod Hopkins 03059 :debster, WI <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Nebster <br /> Address of Issuing Agent (Town, Village,City) County <br /> Webster Burnett <br /> Title: Signature <br /> Zonit>i; Administrator <br />