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VLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Divis`ion'of Health FEE $1.00 P.O.Box 309 NO. 324 1 <br /> (1 Permit per Tanis) Madison,Wisconsin 53701 <br /> Date Issued !/'� /s!'i* <br /> Tank Size gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. Z This permit is for purchase of septic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval (Pink)-TankuRetailer <br /> D <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> ATM CM= Mr. VI 54893 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Sit 214,5 <br /> Plumber's Name License No. Address <br /> I. !MAW MI <br /> Signature of1Person Obtaining Permit Address if Other Than Owner <br /> Mane 51493 <br /> Address of Issuing Agent (Town, Village,City) County <br /> VI <br /> Title: Signature • <br /> MUM aVr tat °'1:f/)/1 a7/ <br /> 4111: / <br />