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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health <br /> FEE $10.00 P.O.Box 309 NO- <br /> 0 Permit per Tank) Madison,Wisconsin 53701 11765 <br /> i Date Issued - <br /> Tank Size gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. - This permit is for purchase of septic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> (blue)-Divislon of Health <br /> Public and/or permits. (Canary)-issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumber's Name License No. <br /> Address <br /> signature oLPefsgn obtaining permit Address if Other Than Owner <br /> Address of Issuing Agent(Tow , Villages City) County <br /> Title: <br /> Signature <br />