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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Divsa n of;-.lealth <br /> FEE $10.00 P.O.Box 309 Na L <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 10/19/78 <br /> Tank Size gal. <br /> 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 (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Y )) Owner's Address <br /> �j j <br /> ut jl..`l Ratite 1, iiox U9, Loretto, MN 5Y,57 <br /> Location (Legal Description) of Property.Where Tank Will be Installed County <br /> ("c-:' SE SEC1! ... 3 .` i 1(14 i::FY:2'It,tt <br /> Plumber's Name License No. Address <br /> Roderick Hopkins i l 3't3JS9 54393 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> ebster, ,vl 54393 <br /> Address of Issuing Agent(Town,Village,City) County <br /> Webster/ter, WI 54893 laurnc:tt <br /> Title: Signature <br /> 1�4'i3 ilz AAm nistrat)r • <br />