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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of HRaith 43524 <br /> FEE $1.00 P.O.Box 309 NO. <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued_ <br /> Tank Size?-50—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 /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> (Biue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address 54W <br /> - <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> SE U SW30 rRN AN NAM I' <br /> Plumber's Name License No. Address <br /> Signature of Person Obtaining Permit Address if ter Than Owner <br /> W1 <br /> Address of Issuing Agent (Town,Village,City) County <br /> Title: Signature <br />