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J$ 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Divisioclof Health NO. 20514 <br /> FEE $10.00 P.O.Box 309 <br /> (1 Permit per Tank) Madison,Wisconsin 63701 <br /> Date Issued 11/24/78 <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 /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (glue)-Dlvislon of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owners Name Owner's Address <br /> Keith Pieter 2982 Frederick PkWY.a blaPleWOOd# MN 55109 <br /> Location(Legal Description) of Property.Where Tank Will be Installed County <br /> NW He SBC7 T40H R15W JACKSON <br /> Plumber's Name License No. Address <br /> AadWiCk H3pkiM GTSW 03059 Mere WI 54893 <br /> ture of Person Obtaining Permit Address if Other Than Owner <br /> Signa <br /> "ObW* WI 54893 <br /> Address of Issuing Agent(Town,Village,City) County <br /> Webster M 54893 <br /> Title: Signature ; <br /> Zoning Altratiac <br />