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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division ot Health NO 56594 <br />. P.O.O.Box 309 <br /> Madison,Wisconsin 53701 <br /> Pee Paid $ LOU <br /> (Each Septic Tank $1.00) STATE SEPTIC TANK PERMIT <br /> �{.�� <br /> Copies: <br /> Date Issued Yom_ ThU pGrUCall Md J1_C__12 for PY�at" O�f��X"t:te tank (Blue)-Tank Rete,tv owner <br /> YW—•not pGrpL YasMileti{Ni Emla (Canary)-Division of Health <br /> State or localapproval md/Or pamits, (Pink) Issuing Agent <br /> Owner's <br /> sNName <br /> �pp��� y�� ��/�ppgnrr� ^^fiAt``� Owner's Address ��r yr.�p���� ��t,I�M��e,! ,�te� <br /> I.=FE&ilfli X&THWW CAMP + 1t P7MM=t 9M.p 5483( <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumber's Name License No. Address BLWWT <br /> I IP ii1075 W= 34 IX1L# Mill, W53 <br /> Signature of P rsonbbtaming Permit Address if Other Than Owner <br /> Address of Issuing Agent(Town, Village,City) County <br /> �=0 �16 <br /> Title: BUOWT <br /> AMMILSTRAM <br /> Signature <br /> — <br />