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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health <br /> FEE $10.00 P.O.Box 309NO. Q 117` 1 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 11/16/79 <br /> Tank Size 1200 gal. <br /> 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 /> (131ue)•Division of Health <br /> Public and/or permits. (canary)-Issuing Agent <br /> Owners Name Owner's Address <br /> Elroy Ferti.l3 113447 Heather St. NW, Anoka, MN <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> SE SE SECTION 14 T40N R15W I Burnett <br /> Plumber's Name license No. Address <br /> Rod Hopkins t-TRW 03059 Webster, .,lI <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> F'Address of Issuing Agent(Tow rV (Mage,_ ity) County <br /> Webs E3su^rlett <br /> Title: Signature <br /> ZonirV; Administrator <br />