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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division NO.of Health <br /> P.O. 53765 <br /> P.OBox 309a7 I <br /> Madison,Wisconsin 53701 <br /> Fee Paid $ <br /> (Each Septic Tank $1.00) STATE SEPTIC TANK PERMIT <br /> !Lt_ purchase� —! Copies: <br /> Date Issued `� pandt is for of � � (White)-Property Owner <br /> only and 40" toot =@M* losallat <br /> tian ira� (Canary) <br /> ( yrank sanary)-Divisionion of of Health <br /> atata ar lot" appiaral and/or pasadxa. (Pink)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Description) of Property Where Tank Will be Installedd County qc MSOr�- <br /> Plumber's Name License No. Address <br /> Signature of Person Obtaining Permit Address if Olhcr Than Owner <br /> Address of Issuing Agent (Town, Village,City) County <br /> Title: 7 —_ Signature <br />