Laserfiche WebLink
PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division ofHeblth 15161 <br /> FEE $1.00 P.O.Box 309 NO. <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued---5,16r <br /> Tank Size 12UU 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 <br /> (Blue)-Division of Health <br /> Public and/or permits. (canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> 3 'tBoom <br /> Plumber's Name License No. Address <br /> WIPAM MPM QM9 WEB13=6 WI <br /> Sigoature of Person Obtaining Permit Address if Other Than Owner <br /> > 4 � .�. vnm=2 V1 <br /> Addfess of Issuing Agent (Town, illage,City) ('ou my <br /> Title: Signature <br /> F <br /> / <br />