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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health 23155 <br /> FEE $1.00 P.A.Qox 39 NO. <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued /10` 7 <br /> Tank Size 750 gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. X 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 Owner's Address <br /> John l oertens 3725 Tyler St. NE, MPLS, °rd 55421 <br /> Location(Legal Description) of Property Where Tank Will be Installed County <br /> SE NE SEC34 '1"s4 fr I?1714 UNION :surnett <br /> Plumber's Name License No. Address <br /> Roderick Hopkins MPR 5:3 03059 ,,ebster, a I 54893 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Bch>tnr, ..I 54893 <br /> Address of Issuing Agent(Town,Village,City) County <br /> Webster, WI 54893 Burnett <br /> Title: Signature <br /> Zoning Administrator <br />