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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> FEE DIP.O. ox 309vision of th 2055 9 <br /> S 10.A0 NO. <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 3« /7` <br /> Tank Size 750 gal. <br /> 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 (Blue)-Tank Retailer <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Lee Bertts1iet rchster WI 54613 <br /> a <br /> Location(Legal Description) of Property.Where Tank Will be Installed County <br /> NW SW SS.''Cc''.3 TI9N R16,4 9eer n 3urnett <br /> Plumber's Name License No. Address <br /> Roderick €opkins ;,t'? aa r, 5} x' <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> ()sfi.�r'� "S )1 �� <br /> Webster, 1541393 <br /> Address of Issuing Agent(Town, Village,City) County <br /> Webster, ' I 543'; i3tf- <br /> Title: Signature <br /> Zoning Administrator <br />