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ff- <br /> DILHR <br /> SANITARY PERMIT COUNTY <br /> TRANSFER/RENEWAL UNI R P R _ <br /> (PLB 67.7) <br /> PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STAT PLAN I.D. NUMBER: <br /> - I - 9q I I -13-9 <br /> PROPERTY LOCATION: CITY: /y� <br /> E '/a Se '/,,S T 3 N,R )(0 E (or TowoF <br /> N : I I !ee�) <br /> LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMA K: <br /> C <br /> PREVIOUS SANITARY PERMIT HOLDER IIF CHANGED): SANITARY PERMIT TRANS=ERRED TO: <br /> NAME: SIGNATURE: NAME: PHONE NUMBER: <br /> ADDRESS: PHONE NUMBER: ADDRESS: <br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this <br /> property. <br /> PLU ER'SSIGNAT REPREVIOUS PLUMBER' AME CHANGE 1: <br /> PLUMBER'S AD ESS: PREVIOUS PLUMBER'S ADDRESS: <br /> abs 8 7o Da land wz <br /> MP/MP SW NUMBER: PHONE NUMBER: MP/MPRSW NUMBER: PHONE UMBER: <br /> �6 ) v 66-866k 307 �l ) a4�--1 <br /> SIGN URE OF ISSUING AGENT: DATE APPROVED: DISTRIBUTION: Original-CoL my <br /> Copy -Burea of Plumbing <br /> q <br /> tiwf L+ / Ir0 Copy-Owne <br /> DILHR-SBD-6399 (R. 5/82) Copy-Plum ger <br />