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PLR, (,S DEPARTMENT OF HEALTl+AND SOCIAL SERVICES <br /> Division of Health NO. 15205 <br /> FEE $1.00 P.O.Box 309 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued_0073 <br /> Tank Sizegal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. = This permit is for purchase of septic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-issuing Agent <br /> Owner's Name Owner's Address <br /> tm = � WX MIM <br /> Location (Legal Description) of Property Where Tank Will be Inssttalled County <br /> 1� s�T <br /> Plumber's Name License No. Address <br /> 301101m= MEE= !01'= mg U—Elam- V1 5" <br /> Sig t e ofperson Obtaining Permit Address if Other Than Owner <br /> i r � <br /> W1 <br /> Address of Issuing Agent (Town, )illage,City) County <br /> 11111111118M WX 5" <br /> Title: Signature (/ <br /> i <br />