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tF4. ,, <br /> PLB. 68, • DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health. NO. i 214 5 <br /> FEE $1.00 P.O.Box 309 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued fit <br /> Ai5 <br /> Tank Size 3200gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. This permit is for purchase of septic tank only and does (White)-Property Owner <br /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (Blue)-Division of Health <br /> Public X and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> OM PIA= RESORT itESTEL, a 54193 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> NE Sit S5C25 INON 815W JACRSON NUM <br /> Plumber's Name License No. Address <br /> ____BODENICK BOP___ MPIISW 03059 M. ill 54693 <br /> Signature of erson Obtaining Permit Address if Other Than Owner <br /> r. .t__. /r` - Ill 54893 <br /> Address of Issuing Agent (Town, Village,City) County <br /> BURNETT <br /> Title: i ne WI <br /> 54893 Signature ,f <br /> iiiAT F - i <br />