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1 p/bx. DEPARTMENT OE HEALTH AND SOCIAL SERVICES <br /> Division of Health NO20156 O 15 6 <br /> FEE 10.00 P.o.eoa xn - L <br /> (I Permit per Tank) Madison,Wisecnsin S 701 <br /> 'Date Issued 5/13/80 <br /> Tank Size 750 gal. STATE SEPTIC TANK PERMIT <br /> copies: <br /> I Private Res. % This permit is for purchase of septic tank only and don Iwnucl-property owner <br /> Isr <br /> not exempt installation from state or local approval lm^kl rano <br /> issue) T ,mcl ,, rinor or Heron <br /> Public and/or permits. (cer's") ne.1on nye" <br /> Owner's NameOwnci s Address <br /> Bernard Gravier 5515 Glenprry Pkwy. , Edina, P44 <br /> Location (legal Dnvdpsion) of Property Where Tank Will be Installed County <br /> NB SE SEL—nON 2 T37N R18H Burnett <br /> Plumber i Name 1Jaenu No. Address <br /> Bryce. Bovingdon 5421 Siren, WI <br /> Signature of Person Obtaining Permit Addmss if other Txan owner <br /> [, SSrasl, III <br /> Address of Issuing Agent (Town, Village,City) County <br /> Webster Burnett <br /> Title: Signature <br /> Zonis¢ Administrator <br />