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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. 09201 <br /> FEE $1.00 P.O.Box 309 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued.sh3/77 <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 exemptinstallation from state or local approval (Pink)-Tank Retailer <br /> p (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> HX= S88= 1 47 3bwgw R140 PAO Conn. 06897 <br /> Location(Legal Description) of Property Where Tank Will be Installed County <br /> Plumber's Name License No. Address <br /> RCK= PROPM MFM W= DAMMAWO dl UM <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> t WI54M <br /> Address of Issuing Agent(Town,,Village,City) County <br /> "amt WI %M <br /> Title: Signature <br />