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PLB. 68 DEPARTMENT OF HEALTH AND'SOCIAL SERVICES <br /> Division of Health 09207 <br /> FEE $1.00 P.O.Box 309 N0. <br /> (1 Permit per�Taankk)�,, Madison,Wisconsin 53701 <br /> Date Issued <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 (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Ownei s Address <br /> HARM IM I DAMMe YI 549*0 <br /> Location(Legal Description) of Property Where Tank Will be installed County <br /> Plumber's Name License No. Address <br /> RICERMIX MPM <br /> Signature of Person Obtaining Permit Address if OtherhannOwner <br /> ++M <br /> Address of Issuing Agent(Town, Village,City) County <br /> Am=* II <br /> Title: Signature <br /> 7AXIM AMOUBTRAM <br />