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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> • Division of Health J ^ <br /> FEE $10.00 <br /> P.O.Box 309 NO. b <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued <br /> Tank Size - 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 /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> (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 /> • <br /> Plumber's Name License No. Address <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent (Town,Village,City) County <br /> Title: Signature <br />