Laserfiche WebLink
Wisconsin Department of Industry, SANITARY PERMIT County <br /> Labor and.Human Relations <br /> Transfer Renewal Sa �13 <br /> Safety and Buildings Division LB 67-T) Uniform Permit Number <br /> Bureau of Building Water Systems �0 <br /> Personal Information you provide may be used for secondary purRoses[Privacy Act s. 15.04 1 m . <br /> Permit Renewal Date Permit Transfer Date Original Permit Issuanc Date State Plan ID Number <br /> 10-1q-0 -a- o <br /> Property Location OV`t• C,o—T- l oo�w'n ❑Village ❑City of: <br /> 5LA 1/4 1/4,9 6 ,T q0 N,R / ✓E(or nW v <br /> Lot Number Block Number bubdivision Name Nearest oad, Lake or Landmark <br /> / U 04, / / <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRED TO: <br /> Name(print) Signature Name(print) Phone Number <br /> Address Phone Number Address <br /> I,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> Plum Sign ure Previous Plumber Name(if changed) <br /> Plumber Ad ss Previous Plumber Address <br /> // /✓ /�V ��eK 78 % - c l#D <br /> / FIF<6VV Number Phone Number Z M MPRSW Number Phone Number <br /> 71-4-- W - 12608 <br /> Issuing Agent Signature Date Approved <br /> SBDW-6399(R.04/95) Distribution:Original-County; Copy-Bureau of Building Water Systems; Copy-Owner; Copy-plumber <br />