Laserfiche WebLink
Wisconsin Department of Industry, SANITARY PERMIT <br /> It,abor acid Human Relations county <br /> ransfer / enewal 13U rn _ <br /> Safety and Buildings Division LB 67-T) Uniform Permit Number <br /> Bureau of Building Water SystemsI lO ,(J�y� �(a <br /> Personal Information you provide may be used for seconds ur oses[PrivacyAct s. 15.04(1)(m)]. —� b V <br /> Permit Renewal Date Permit Transfer Date Original Permit Issuance Date State Plan ID Number <br /> - <br /> Property Locationtl�r1 n <br /> wn Qvillge City of: <br /> NJO 1/4 r V 1/4,S ,T N,R E(or W <br /> Lot Number loc Number u i ame Nearest Road,Lake or Landmark <br /> a l.a <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRED TO: <br /> Name(print) ignature Name(print) Phone Number <br /> Address I Phone Number Address <br /> I,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> Plumbe S' nature Pr ' us Plumber Name(if c ange ) <br /> i l'q S <br /> PI ber A dress Previous Plumber AtjL. <br /> s <br /> ��r (�L 5k$� a-773s UVB '518q <br /> MP/MPR W Number Phone umber M / W Number Ph ne Number <br /> Issuing Agent Signature Date Approved <br /> SBDW-6399(R.04/95) Distribution:Original-County; Copy-Bureau of Building Water Systems; Copy-Owner; Copy-plumber <br />