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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health 5540 <br /> 'FEE $10.00 P.O.Box 309 NO. <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued /2E>/IFs <br /> lfoldi-tigi l�fx) <br /> Tank Size gal. STATE SEPTIC TANK PERMIT <br /> 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 (Blnk)-Tank Retailer <br /> Public and/or (Blue)-Division of Health <br /> permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Description) of Property.Where Tank Will be Installed County <br /> 3; 5! ,( T39,.' R 4G Burnett <br /> Plumber's Name License No. Address <br /> ..cnlerick Hopkins Signature of Person Obtaining Permit Address if Other Than Owner <br /> inter, ;Vsl 54893 <br /> Address of Issuing Agent(Town, Village,City) County <br /> Title: <br /> Signature <br /> ZQnitl I3ci i z tratrcr <br />