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f <br /> PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICESof <br /> FEE $1.00 Division <br /> P O.Box 309th NO. 09279 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 7n <br /> Tank Size750_gai. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. E 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 /> Location(Legal <br /> Description) of Property <br /> WhereTankWill be Installed County <br /> SW =i �3 11 M $ilk �y�y BER <br /> Plumber's Name License No. Address �+•AW <br /> ICBM= RDA= XFM 033()59 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> 54M <br /> Address qo�f Issuing Agent(Town, Village,City) County <br /> � <br /> 9 WI 54M BMJM <br /> Title: Signature <br /> Z �� <br />