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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health -? 9 <br /> 6 <br /> FEE,$1.00 P.O.sox 309 NO. ._ <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> •Date Issued 7— <br /> .27 <br /> Tank Size gal. <br /> STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. This permit is for purchase of spetic tank only and does (white)-Property Owner <br /> ( <br /> not exempt installation from state or local approval Tank Retailer <br /> (Canary)-Division of Health <br /> Public and/or permits. (Pink)-issuing Agent <br /> Owner's Name Owner's Address) <br /> Location (Legal Description) of Property Where Tank Will be Installed / � County <br /> S(CJ V , . /�{, lt) 1 5 W C S (r( // <br /> Plumber's Name License No. Address <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> psi + <br /> Address of Issuing Agent(Town, Village 'ty) County <br /> Title: Signature/ __ <br />