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DEPARTMENT OF�HEALTH AND SOCIAL SERVICES <br /> }�• ` Division of Health 21446 <br /> �q j C <br /> $1.00 sr" "':- P.O.Box 304 NO <br /> (1 Permit per Tan y i <br /> Madison,wisconsin 53701 <br /> Date Issued / <br /> Tank Sizes—gal• STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. This permit is for purchase of septic tank only and does (white)-Property owner <br /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (Bine)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name <br /> Owner's Address <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumber' Name <br /> License No Address <br /> f/ .t <br /> Sig re 1 Pe(/Is n Ob[aillung Pergaut Address if Other Than Owner <br /> t fr f` [�in' <br /> ddress of Is #gent (Town, Village,City) <br /> County <br /> 11 <br /> Ti le: + <br /> • Signature - <br /> r <br />