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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. 14 016 <br /> FEE $10.00 P.O.Bax 309 <br /> (I Permit per Tank) Madison,Wisconsin 63701 <br /> Date Issued <br /> Tank Size , Bal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res.'` 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 /> Location(Legal Descrip ion) of Property.Where Tank Will be Installed County <br /> Plumber's Name License No. Address <br /> i <br /> Sruat,neL <br /> of Perron Obtaining it Address if Other Than Owner <br /> ss of Issuing Agent (TO)4n,Village,City) County <br /> .tie. ... Signature <br />