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E PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Divisial of Health <br /> FEE $1.00 ,. — P.Q.Box 309 NO. I }f 6 0 2 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 i3 <br /> Date Issued 3/28/74 <br /> 750 <br /> Tank Size gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. Z This permit is for purchase of spetic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval ( Tank Retailer <br /> (CC anaranary)-Division of Health <br /> Public and/or permits. (Pink)-Issuing Agent <br /> Owner's Name Owner's Address <br /> RUM GREINEE R UTE 1 BOX 138 S ail 54E72 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Soli 511 SEC27 T38N R17ii DANIELS BUIDETT <br /> Plumber's Name BCVVE DCN License No. Address <br /> RP 5421 ROUTE 1 SIM, .iI 54872 <br /> Signature of Per§on Obtaining Permit Address if Other Than Owner <br /> icy SIREN, I 54872 <br /> Address of Issuing Agent (Town, Village,City) County <br /> triSSTEN, atI 54893 BURWIT <br /> Title: Signature <br /> ZONING JI`DMINISTRATCa <br />