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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> • <br /> Division of Health <br /> FEE $10.00 P.O.Box 309 NO. <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 7/1:,/ ' <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)-TankRetailer <br /> D <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Glenn G. Nelson 4716 — 103 Lane N , MPTX, MN <br /> Location(Legal Description) of Property.Where Tank Will be Installed County <br /> 3 LC13 'T4tt't R15w #66 Great — Voyager Village Burnett <br /> Plumber's Name License No. Address <br /> I;orlalf.3 Proffit : 7)P. O72 1-.... y-'a s a :iI 54330 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Dairyland, s'Jt 54330 <br /> Address of Issuing Agent(Town, Village,City) County <br /> <eh,ter, WI 54893 Eurnett <br /> Title: Signature <br /> Zoning Administrator <br />