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PLB. 6$. • DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health 21414 <br /> FEE $1.00 P.O.Box 309 ' NO. <br /> (1 Permit per Tan ) Madison,Wisconsin 53701 <br /> Date Issued 9/5/75 <br /> Tank Size 12()0 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 exempt installation from state or local approval (Pink)-TankRetailer <br /> (Blue)-Division(Canary)-Issuing <br /> Public and/or permits. ( nary))IIsuing Agent <br /> Owner's Name Owner's Address ` <br /> RESORTCUR PUCE TER, i , <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> BE SE SEC25 T4ON B15W JACKSONi BURNETT <br /> Plumber's Name License No. Address <br /> RODERICK b )W= NMI 03059 WEBSM, WI 54893 <br /> Signature of erson Obtaining Permit 1^ '1 Address if Other Than Owner <br /> 4 +( ! WI 54893 <br /> Ad ress of Issuing Agent (Town, Village,City) County <br /> MGM, WI 54893 <br /> Title: Signature <br /> / <br /> ZOOM ADKINISTRMR /. ff. fr, f f, / <br />