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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. 09269 <br /> — <br /> FEE 51.00 P.O.BO%309 <br /> (I Permit per Tank) w�vs. Madison,Wisconsin 53)01 <br /> Date Issued 613fV <br /> Tank Size750 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 /> hank)-Tdnk Retain <br /> not exempt installation from state or local approval (Bice)-Division or Health <br /> Public and/or permits. (canary)issuing Agent <br /> Owner's Nam. Owner's Address <br /> PSTN OUIM 726 Address <br /> ArlirtgUm, Ste P=1 cot 55106 <br /> Location(Legal Dewnption) of Property Where Tank Will be Installed County <br /> UJ BS SE033 T40 R15N JACBSOB #41 K llnsw GMM I BEIRZ +TP <br /> Plumber's Name license No. Address <br /> tio <br /> HatFx »oiK= Htasa 03059 EMS=, cal 54893 <br /> Signature of Person Obtaining Permit Address if Other I ban owner <br /> iI _ ��, dl Jsix+7J <br /> Address of Issuing Agent(Town,ViBagc,City) County <br /> IlMSM <br /> Titk: Signature <br /> Z011= ADMIMTBATOH <br />