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Plb #67 7/71 <br /> Wisconsin Department of Health and Social Servioss' <br /> Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE OR USE BLACK INK - PLEASE PRINT <br /> A, OWNER OF PROPERTY <br /> Name Address ptilet, City, Zip Code) <br /> r � _ <br /> B. LOCATION OF PROPERTY WHERE SYST WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY i <br /> Check Onet <br /> CITY 7 YI GE LEGAL DESCRIPTION <br /> TOWNSHIP '��:: (Block, Lot, Seo,) <br /> C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? � YES No PERMIT N[MBER <br /> D. SEPTIC TANK CAPACITY GALLONS NEW INSTALLATION �j REPLACEMENT_ ADDITION_ <br /> MATERIALS: PREFAB CONCRETE 4 POUVD IN PLACE_ STEEL_ OTHER <br /> NUMBER OF TANKS TO BE INSTALLED: / <br /> E. TYPE OF OCCUPANCY <br /> Check Onet One or Two Family Residence Commercial Industrial_ Other-(Specify) <br /> Number of persons to be Accommodated_ Number of Bedrooms <br /> F, APPLICANCES, ETCs Food Waste Grinder YES J0 Automatic Clother Washer YES �/'y0 <br /> Dishwasher YES ANO Automatic Potato Peeler YES _NO <br /> OTHER (specify) YES _e NO <br /> G. MASTER PI�IRSIDEF,N 'KING INSTALLATION <br /> Names Address& <br /> SIGNATURE OF APPLICANT:._ ' <br /> / , License Number: MP > <br /> ADDRESS: -! M,p�p, 1 <br /> H. (TO BE COMPLETED BY ISSUING AGENT) <br /> Date of Application Fee Paid <br /> Permit Issued (date) Permit Number <br /> Agent (name) Fors <br /> tarn, village, city, county, etc, (specify) <br /> NOTE: The Application cannot be considered for filing until all of the above questions are answered <br /> and the fee paid. Agents will forward application, the fee of $1.00 for each septic tank and <br /> the third copy of the permit (canary) to the Division of Health. Checks and money orders should <br /> be made payable to the Division of Health. <br /> COMPLETE OTHER SIDE <br />