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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health I5�244 <br /> FEE $1.00 P.O.Box 31x9 NO. <br /> (1 Permit per Tank) Madison,Wisconsin 63701 <br /> Date Issued-_ <br /> Tank Size 71200 gal. STATE SEPTIC TANK PERMIT <br /> copies: <br /> Private Res. y 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 (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> lo('sMxadu 5t3Fla yr <br /> (Maim) <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> 19 U .SECT T40N &UW SMTT BLmjsrr <br /> Plumber's Name License No. Address <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> =—snag WI <br /> J t <br /> Address of Issuing Agent (Town, Village;City) Countv <br /> � rir7J <br /> Title: Signature <br /> SON= k <br /> i <br />