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PLB. 68 ' DEPARTMENT OF HEALTH AND SOCIAL SERVICES _ n f��p7 <br /> `division o�Healm NO. O J 2.J 1 <br /> FEE $1.00 P.O.Bo.309 <br /> (I Permit par <br /> ,sTaansks)/�s Madison,Wisconsin 53)01 <br /> Date Issued <br /> Tank Size ?50 gal. STATE SEPTIC TANK PERMIT <br /> coeles: <br /> Private Res. S This permit is for purchase of septic tank only and does iWaite).Prooeay owns. <br /> (Wnki-Tank Retailer <br /> not exempt installation from state or local approval ieluepoivision of Health <br /> Public and/or permits. tcaoarvl-I..w re ueent <br /> Owner's NameOwner's Address <br /> MVM VM FSTEMS 2701 Bailiff Placa Mpla. FZ 55431 <br /> Location(Legal Description)of Pmpcny Where Tank Will be Installed County <br /> sw uw s= YOB Ri6N <br /> Plumbci s Name License No. Address <br /> B.OIIEB=K BOF EMU 03059 tffiT1R, NI 54893 <br /> Signature of Person Obtaining Permit Address if Othes Than Owner - <br /> W=7M MI 54893 <br /> Address of Issuing Agent (To�wpn, Village,City) County <br /> mirm, Vi <br /> Title: Signature ` <br /> i- <br /> �f <br />