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Wisconsin Department of Industry, .SA Y P T Count <br /> Labor and human Relations coun <br /> Transf / Renewal <br /> Safety and Buildings Division (r)LB g _ Uniform Permit Number <br /> Bureau of Building Water Systems 7 �l q 71�6 <br /> Personal Information you provide may be used for secondary puroses TPrrvacy Act s. 15.04 1 m . <br /> Permit Renewal Date Permit Transfer Date Original Permit Issuance Date State Plan ID Number <br /> H-a - d-aI 5%- 20-f5_70 <br /> ao3_7o <br /> Property Location C> Town ❑Village El City of: <br /> 1/4 1/4,S 1�O .T 3� N,R � E or W <br /> of umber loc umber ubdivision ame eare Road ake or Landmark <br /> Cpm V. <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRED TO: <br /> Name(print) ignature Name(print) Phone Number <br /> �h I-) (old,- 87 <br /> A dress one Number Address <br /> I,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> Plumber Signature Previous Plumber Name(if changed) <br /> Plumber Address Previous Plumber Address <br /> MP/MVV Num er hone Number MP/MP Number Phone Number <br /> 3-3� � -)as <br /> Issuing Agent Signature LfflDate Approved `7 -2%— g <br /> SBDW-6399(R.04/95) Distribution:Original-County; Copy-Bureau of Building Water Systems; Copy-Owner; Copy-plumber <br />