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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health 21449 <br /> FEE $1.00 P.O.Box 309 NO. <br /> (1 Permit pe Tank). Madison,Wisconsin 53701 <br /> Date Issued? <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 /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (Blue)-Division of Health <br /> Public and/or permits. (Canary)-issuing Agent <br /> Owner's Name Owner's Address <br /> 77 <br /> Location (Legal Description) of Property Where Tank Will <br /> �bee Installed t / County <br /> Zj <br /> Plumber's Name / License No. Address <br /> wr <br /> Signature of Person Obtaining Permit ff Address if Other Than Owner <br /> i <br /> Address of Issuing Agent ( owiy illage,City) County <br /> J <br /> Title Signature f <br />