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PLO. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health 15697 <br /> FEE $1.00 P.O.Box 309 NO. <br /> (1 Permit per TTarf) Madison,Wisconsin 53701 <br /> Date Issued JJ <br /> Tank Size 750 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 /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Evergreen and .ASsmiatta RcpAi It t WI <br /> Location(Legal Description) of Property Where Tank Will be Installed County <br /> Sid sw =4 Ttm a6w Ott <br /> Plumber's Name license No. Address <br /> Rod ftyki le unit 03059 Webstsrs W1 54M <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent(Town,Village,City) County <br /> Web tors WI 54" Burnett <br /> Title: Signature <br /> ZGIt>13?ig d.>aitrater <br />