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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health No. 15622 <br /> FEE $1.00 P.O.Box 309 <br /> (I Permit per Ta k) Madison,Wisconsin 53701 <br /> Date Issued $ <br /> /15/77 <br /> Tank Size 1200 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 /> 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 /> —DUAue John8on I Giantaburg, WI 5 0 <br /> Location(Legal Description) of Property Where Tank Will be Installed rBUXU"t <br /> unty <br /> AW 39 = 5 Rl� <br /> Plumber's Name License No. Address <br /> Bala Last= HP 5784 ROU" 2; imbstwiWt WI 54M <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent (Town, Village,City) County <br /> W ebetW>E W1 %M Ott <br /> Title: Signature <br /> Zoning Adlinistrstor <br />