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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. 3392 <br /> FEE $10.00 P.O.Box 309 <br /> Madison,Wisconsin 53701 <br /> (1 Permit per Tank) <br /> Date Issued <br /> Tank SizeBal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> This permit is for purchase of septic tank only and does (White)-Property Owner <br /> Private Res. (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (Blue)-Division of Health <br /> and/or permits. (Canary)-Issuing Agent <br /> Public- <br /> Owner's <br /> ublicOwneis Name owner's Address <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumber's ale License No. Address <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> County <br /> Address of Issuing Agent (Town, Village,City) <br /> Title: Signature <br /> s <br /> I� <br />