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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health Na 0 9 2 5 7 <br /> FEE $1.00 P-.O.Bbx 309 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 6/21fl7 <br /> Tank Size751? 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 /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> )-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> RICHARD it LLEN 1583 Rivercrest Rd N., Lalcialauda MN 55Q1i3 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Sit 16S1Cll TON R154dACISCE BURNETT <br /> Plumber's Name License No. Address <br /> RODERICK HOPKINS MPRSW 03059 WEBSTER. in 54893 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> i llat WI 548 3 <br /> Address of Issuing Agent (Town,Village,City) County <br /> ieLBSTER, WI 54893 BURNETT <br /> Title: Signature <br /> ZONING At E:LE'TRA R <br />