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PLB 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES " <br /> Division of Health No. 43511 <br /> FEE$1.00 P.O.Box 309 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued_ <br /> Tank Sizd#4$0—ga). STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. Z 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 /> 9996 NU 55932 <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> 1 h'. <br /> Plumber's Name License No. Address <br /> B� �PK7 Now 0309 <br /> €ASTER, a 5 93 <br /> Signature of Person Obtaining Permit Addd�ress++i��ffp Other Than <br /> AIt 7hhan Owner <br /> ++ss� <br /> AddressIssuing-Agent <br /> of Issuing Ant(Town, Village;City) County <br /> Title: Signature j <br /> ZOM 1M 3A 1 <br />