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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES A <br /> Division of Health L`� L <br /> FEE $1.00 NO.-Box 309 NO. 77 <br /> (1 Permit per.Tank) Madison,Wisconsin 53701 <br /> Date Issued <br /> Tank Size 1©� 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 /> (Blue)-Tank Retailer <br /> not exempt installation from state or local approval <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's NameOwne Address <br /> J i dI <br /> Location (LLeegal D'<eessc`ripti� of Property W ere Tank Will be Installed Coun� <br /> Plumber's Name License No. Address <br /> A0dWriek Ho ij= 4*69 Arlt 11T <br /> Sig re of Person Obtaining Pe it Adqiifis if Other Than Owner <br /> JL <br /> Address 9T Issuing Agent own, Village,City) County <br /> 7 Asbetw W1 <br /> Title Zonim at� Signat • <br />