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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. 1560 /� <br /> FEE $1.00 P.O.Box 309 `t <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued $"l'"'77 <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)-TankRetailer <br /> not exempt installation from state or local approval <br /> (Blue)-Division of Health <br /> Public and/or permits. (canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Edward Farrell 5409 Emerson Ave, MIls, MN <br /> Location(Legal Description) of Property Where Tank Will be Installed County <br /> ,Si Si SEC17 WA R15W Sirnatt <br /> Plumber's Name License No. Address <br /> Ronald g Profit t 03072 Dai.ry]aad, WI <br /> Sig erson Obtaining Permit Address if Other Than Owner <br /> x c <br /> „..,...--r.--447.1 <br /> Address of Issuing Agent (Town, Village,City) County <br /> Webster, WI 54893 Burnett <br /> Title: Signature <br /> Zoning Administrator <br />