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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Div:sior.of Health Q � <br /> FEE $1.00 P.O.Box 309 NO. a <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 10104 <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 /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> Dank <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address ` <br /> JONI POIrA&D Lace Nplas, NN 55421 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumber's Name License No. Address <br /> Ng * IiI <br /> Signattl'te"of Person Ob njng rmrt: ' Address if Other Than Owner <br /> Address of Issuing Agennt��(TTo�own, Village,Cit County <br /> infiSTRa, VI r d auwarr <br /> Title: Signature i <br />