Laserfiche WebLink
PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of ..Jth NO. 43572 <br /> FEE $1.00 P.O.Box 309 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued <br /> Tank Size%, ..gal. STATE SEPTIC TANK PERMIT <br /> copies: <br /> This permit is for purchase of septic tank only and does (White)-Property Owner <br /> Private Res.' P p (Pink)-Tank Retailer <br /> not exempt installation from state or local .approval (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name <br /> O <br /> wner's <br /> 7 <br /> Location (Legal Description) of Property Where Tank Will be Installed �C`punty <br /> Plumber's Name License No. Address <br /> i <br /> Signature of PTson Obtaining Permit Address if Other Than Owner _ <br /> Address of Issuing Agent (Town,Vitlage,City) County <br /> Title: Signature / <br />