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PLB. 68' DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health <br /> ^ o EE $10.00 P.O.Box 309 NO. L <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued r,%;/16/78 <br /> Tank Size 750 gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res.'s 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 <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Fbward Griffin ,;.tfA.1 Like? <br /> Location (Legal Description) of Property.Where Tank Will be Installed County <br /> n4 SE SFC23 TIM t.5' is1a#.aj° .. <br /> i-urn 'tt <br /> Plumber's Name License No. Address <br /> .<R '..1PRFa 3051 Shell Lake, a: 54d71 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Cpcil Scribner Shell Like, ;a1 54671 <br /> Address of Issuing Agent (Town, Village,City) !County <br /> ':. x,ter, =;.'I 54893 tt <br /> Title: Signature <br /> Zoning Administrator <br />