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Wisconsin Department of Industry, SANITARY PERMIT EPermit <br /> Labor and Hunan Relations Transfer Renewal � <br /> Safety and Buildings Division (PLB 67-T) ber <br /> Bureau of Building Water Systems )lq 399'ss <br /> Personal Information ou rovide ma be used for seconda ur oses Privac Act,s. 15.04 1 m . <br /> Permi enewal to Permit Transfer Date Original Permit Issuance Date State Plan ID Number <br /> to - d3 9-6) 1 <br /> Property Location Town E]Village ❑City of: <br /> i 34 17 E(or ►i�ls <br /> 1/4 1/4,S / ,T N,R earest Road,Lae or Landmark <br /> Lot umber Block NUMDer Subdiv Name <br /> Csrn V I pa Cpm )eCL <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRED TO: <br /> Name(print) g <br /> nature Name(print) Phone Number <br /> -e r I e Ce 7+� rr�zn <br /> Address Phone Number Address <br /> -77 �� ► 2d 719- 38i- szl�� <br /> N-r-tdS -U01 <br /> I,the undersigned,assume responsibility or installation of the private sewage system that has been previously approved for this property. <br /> Plu er Signatu e Previous Plumber Name(if changed) <br /> Previous Plumber Address <br /> Plu ber Address , 4rhu�.. <br /> c7) <br /> ��M /M R Number Number M /M RSW NumberPhone Number/MP3-3o ��iSI3 - 3y1 X5'3 <br /> Date Approved <br /> Issuing Agent Signature Copy-P <br /> Owner; Co lumber <br /> SBDW-6399(R.04/95) Distribution:Original-County; Copy-Bureau of Building Water Systems; Copy- <br />