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# ILB- 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. 48182 <br /> P.O.Box 309 <br /> t{tp[ Madison,Wisconsin 53701 <br /> Pee Paid S1,00 <br /> f (tach Septic Tank $1.00) STATE SEPTIC TANK PERMIT <br /> I Copies: <br /> Uu[c Issued 10 2 (Whte)-Property Owner <br /> Tp@L7iitt�Is for ptl rchass Offs siptie teak (BlulThise)Tank Retailer <br /> may ssd Wes nat s t JMIPAII ties fros (Canary)-Division of Health <br /> state eir local approval ssa/s! pera (Pink)-Issuing Agent <br /> Owner's Name <br /> Owner's Address '�lM <br /> GlORIM AMUF 7200 = ATE= 9 XONUML09 !IIS(. 55429 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> JACMN SE Z SBC, 14 T40 RUW BURIWT <br /> Plumber's Name License No. Address <br /> 1, R4AW 4631 WB$4ZSR, n30016n <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> kusmv WL4CMIN <br /> Address of Issuing Agent (Town, Village,City) County <br /> mmmat W==3X SURMT <br /> Title: Signature <br /> ZCM= ADEDIISTRA= <br /> f. <br />