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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. r. <br /> FEE $10.00 P.O'Box 309 �' <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 5/16 79 <br /> Tank Size 12,0 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 /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Description) of Property.Where Tank Will be Installed County <br /> SE SW SEC19 T4ON R 6W OAKLAND t <br /> Plumber's Name License No. Address <br /> Prof.fi t APr(S s 03Q'f 2 r airyland, WI 54833 <br /> • <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Dair'ylar , WI 54830 <br /> Address of Issuing Agent (Town, Village,City) County <br /> Webster., Z 54891 burnett <br /> Title: Signature <br /> Zoning Administrator <br />