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i <br /> State of Wisconsin County <br /> Department of Commerce SANITARY PERMIT 50[2"17 <br /> Safety and Buildings Division Transfer/Renewal uniform Permit Number <br /> Integrated Services Bureau -�-7e <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 Date Original Permit Issuance Date State Regulated Object <br /> 5- /q- 05 <br /> Property Location id Town ❑ Village ❑ City of <br /> 1/4 1/4,S ,T N.R E(or)IN RUSK <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,State,Zip Code <br /> I,the undersigned,assume respons' ility fo slallation of the private sewage system that has been previously approved for this property. <br /> Plumber ature _ Pre ious Plumber��ame(if changed) <br /> �Gv2` l3lDIE <br /> PI b ddress Previous Plumber address ``�11 <br /> 0. oX �� Slzel�/A14l� V 119,50 C AO a ulAa U�1 S�{$�3 <br /> -IRP/MPRSW umber Phone Number •MPlhtt6lN Number hone Number <br /> ( 7iS ) bbd µ 4 61 Z L o/5 ) ro 1� 351 <br /> Issuing Agent Signature Date Approved <br /> SBD-6399(R.4/99) <br /> 9--77-T <br />