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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. <br /> FEE$1.00 P.O.B»x'309 �'}��� <br /> (1 Permit per Tank) `t Madison,Wisconsin 53701 G <br /> Date Issued / ^z <br /> Tank Size =" ' gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. This permit is for purchase of spetic tank only and does (white)-Property Owner <br /> (Blue)-Tank Retailer <br /> ISI not exempt installation from state or local approval (canary)-Division of Health <br /> Public = / ' and/or permits. (Rink)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Description) of ProiSerty Where Tank Will be Installed County <br /> Plumber's Name Incense No. Address <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Add regs of Issuing Agent(Town,Village,City) - County <br /> Title: Signature <br />