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Plb #67 7/71 Wisoarin Department of Health and Social Services <br /> Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE OR USE BLACK INK - PLEASE PRINT <br /> L. OWNER OF PROPERTY <br /> Name Address (Street, City, lip Code) .5- .9-a <br /> cN All, <br /> B. LOCATION OF PROPERTY WHERE SYST WILL BE CCNSTRUCTED ALTERED OR EXTENDED COUNTY. ^�•✓i-,'i <br /> Cheek Onet <br /> CITY VILLAGE LEGAL DESCRIPTION <br /> rOWNSHI?�. (Block, lot, Seo.) <br /> C. iS ! CAL PERM!' kkwUIRED FOR THIS WORK? No PERMIT N'"KR <br /> '7. SEPTIC TANK .74PACITY " 'C`, GALLONS WEW 1NST.'LLATI"N_ REPLA. EMENT_ ADDITION_ <br /> MATERi ALSs P?E'F'+c )!JCRE'rE x PUURfD !N � ,,CE-- STEEL--_ OTHER <br /> -- <br /> NltiB;KR OF PANKS TO BE INSTA LLEO <br /> E, TYPE PF 'X.JCPANCY <br /> OF�acx Onet <br /> On -�r vo Family nesidenc e_y_ Commercialira+mat^ixl Other_(Specify) <br /> Nu me er of PLrecos to be zCeeaunodated�� N�: Ler C' 2-1drooms�_ <br /> :nrfe t, n�nn . ;•.r Pe,ler zE5 No <br /> �. P.Ab:'Gr _'.1'c._.. i.,....`;r} F?J.•.iA..LA'ii JN <br /> Names .. Addr'eae, .. _ <br /> S' ?;ATT,Rr. uF 4,Ri ICANTI - <br /> License Numbers NJ' <br /> H. (TC BE c',w ETED BY IS?JING AGENT) <br /> Date of Applloation Fes Paid <br /> Permit Issued (date) Permit Number <br /> Agent (name) Fort <br /> tame village, a1iy, county, etc, apsollyr) <br /> NOTEt The Application cannot be considered for filing until all of the above questions are answered <br /> and the fee paid. Agents will forward application, the fee of $1.00 for each septic tank and <br /> the third copy of the permit (canary) to the Division of Health. Checks and money orders should <br /> be made payable to the Division of Health. <br /> COMPLLTL OTHER SIDt <br />