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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health No. 09293 <br /> FEE $1.00 P.O.Box 309 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued <br /> Tank Size ltd gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. it This permit is for purchase of septic tank only and does (White)-Property Owner <br /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> LAME= BRANSW I GUMEMGtdl 5 <br /> Location(Legal Description) of Property Where Tank Will be Installed County �r7p t�f qq� <br /> JA Md SM 41 q �` i7MLL�ih1i <br /> Plumber's Name License No. Address <br /> B BCYLmu HP 5421 SM099 JI 54872 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> S3= WI 5W2 <br /> Address of Issuing Agent(Town,Village,City) County <br /> Wl 3403 <br /> Title: Signature <br /> ZOKM MOM <br />