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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> -Division of Health <br /> FEE $10.00 P.O.Box 309 NO. b 5 1 1 <br /> (1 Permit pgr Tank) Madison,Wisconsin 53701 <br /> Date Issued 6/5/78 <br /> Tank Size 1000 gal. <br /> STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res.X This permit is for purchase of septic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval (Blue)-Tank Retailer <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Tom Jansen 782 Lincoln Ave., St. Paul, IAl 55105 <br /> Location(Legal Description) of Property.Where Tank Will be Installed County <br /> SW SW SEC19 T41t R15W SWISS Burnett <br /> Plumber's Name License No. Address <br /> Nola Foerper HP 5784 Webster, WI 54893 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Webster, WI 54893 <br /> Address of Issuing Agent(Town,Village,City) County <br /> Webster, 4I 54893 Burnett <br /> Title: Signature. <br /> f <br /> Zoning Administrator �` <br />