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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. 23182 <br /> FEE $1.00 P.O.Box 309 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued '/217 <br /> Tank Size !.?`'' 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 /> Geor&e ttetttrer 1230 Ripley Ave., =1c1 1ewoad, MN 55109 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> NE SW SEC35 T4=O € R154 JACKSO Burnett <br /> Plumber's Name License No. Address <br /> Roderick tiopkirt;. 1 ,`i `3 `3`it',a.fi! ,!j 5ff::93 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> ��_:�s t. �r, 'A 54)(7.3 <br /> Address of Issuing Agent(Town, Village,City) County <br /> tor, _ 7 ..i r. t <br /> Title: Signature <br /> Zoning Acildititittrator <br />