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Stateo <br /> t Wisconsin SANITARY PERMIT county <br /> Department ament of Commerce goyZa�7 <br /> Safety and Buildings Division Transfer/Renewal Uniform Permit Number <br /> Integrated Services Bureau <br /> Personal information you provide may be used for secondary purposes[Privacy Law, s. 15.04'1)(m)i. <br /> Permit Renewal Date Permit Transfer Dale Original Permit Issuance Date State Regulated Object <br /> /1-4-05 5- iq- o5 <br /> Property Location Town ❑ Village ❑ City of <br /> 1/4 1/4,S ,T N.R E(or)W R03y- <br /> Lot Number Block Number Subdivision Name Nearest Road, Lake or Landmark <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRED TO <br /> Name(Please Print) Signature Name(Please Print) Phone Number <br /> Address Phone Number Street Address,City,Slate,Zip Code <br /> ( ) <br /> I,the undersigned,assume respons' ility fo stallation of the private sewage system that has been previously approved for this property. <br /> Plumber sture Prrey/jMous Plumber ame(it changed) <br /> PI -dress 7ATP-` � <br /> Previous Plumber address ``��t� <br /> 0. �X I(aD 56te1/�w�e � S-VV 10 G AO A cJAa 0 Sd$�3 <br /> RIPIMPRSW umber Phone Number •MP/h�M Number Phone Number <br /> ( 7< > `fid SI ( 71 ) 6 '� 3571 <br /> Issuing Agent Signature Date Approved /(161`/6Ls <br /> SBD-6399(R.4/99) <br />