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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health 28733 <br /> P.O.Box 309 NO. <br /> Madison,Wisconsin 53701 <br /> Fee Paid $ 140 <br /> (Each Septic Tank $1.00) STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Date Issued In (White)-Property Owner <br /> (Blue)-Tank Retailer <br /> (Canary)-Division of Health <br /> (Pink)-Issuing Agent <br /> Owner's Name Owner's Address <br /> YS MON 1101112 2,, CMAIIIENUM# <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> UM WIZ Sit St Me. 21 Val Mal WM= <br /> Plumber's Name <br /> ♦ License No. Address <br /> WSW siA 5 <br /> Signature of Person Obtaining_Pe iit Address if Other Than Owner <br /> Address of Issuing Agent (Town, Village,City) County <br /> Title: Signatures! <br /> MUM ALMA <br />