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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division ot-Health <br /> FEE $10.00 P.O.Box 309 NO- 20582 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued <br /> Tank Size gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. 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 /> (Blue)-L]Iv islon of Health <br /> Public and/or permits. (Canary)-issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Description) of Property.Where Tank Will be Installed County <br /> Plumber's Name license No. Address <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent (Town, Village,City) County <br /> Title: I Signature <br />