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PLB. 68 DEPARTMENT OF HEALTH-AND SOCIAL SERVICES <br /> Division of Health FEE $1.00 P.O.Box 309 NO. V V <br /> � <br /> (1 Permit per Tank).s r Madison,Wisconsin 53701 <br /> Date Issued 'L.` :-) <br /> Tank Size gal. STATE SEPTIC TANK PERMIT <br /> fir. 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)-Tank Retailer <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> ` /} <br /> Location (Legal Description) of Property Where Tank Will be Installed / County <br /> J. f �1 <br /> / � // <br /> Plumber's Name License No. Address <br /> r l / 1� . <br /> iii <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent (Town, Village,City) County / <br /> Title: Signature / <br /> ;if .I(./ 1 ( l(lh1(77( - )7/7 ' /I _.) /9/7 07/ <br />