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PLB. rg DEPARTMENT OF.HEA LTH AND SOCIAL SERVICES <br /> Division df Health NO 21401 <br /> 1 / 0+ <br /> FEE S I.00 P.O.Box 309 j,�} j <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> 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)-Division of Health <br /> Public and/or permits. (Canary)-issuing Agent <br /> Owner's Name Owner's Address <br /> Location (Legal Desenpt n) of Property Where Tank Will be Installed County <br /> Plumber's lame J License No. Address <br /> Signature of Perso Obtaing Permit' Address if Other Than Mner <br /> Address of Issuing Alent (Town, Village,City) County <br /> Title: Signature <br /> aLl <br /> C y y <br /> t <br />