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* <br /> State ofWisconsin SANITARY PERMIT County <br /> Department artment of Commerce <br /> Safety and Buildings Division Transfer/Renewal Uniform Permit Number <br /> Integrated Services Bureau 45'� Ov/ <br /> Personal information you provide may be used for secondary purposes[Privacy Law, s. 15.04(1)(m)j. � . <br /> Permit Renewal Date Permit Transfer Date Original Permit Issuance Date State Regulated Object <br /> /.2 .Sale 225 /,2 Se `05 g j�4y 04 <br /> Property Location X Town D Village D City of <br /> 1/4 1/4,S i6 ,T ya N.R /& E(or) O'1k1a <br /> Lot NumberNumber Subdivision Name Nearest Road,Lake or Landmark <br /> 3 Block Rainbow Ln <br /> PREVIOUS SANITARY PERMIT HOLDER—IF CHANGED: SANITARY PERMIT TRANSFERRED TO <br /> Name(Please Print) Signature Name(Please Print) Phone Number <br /> RY,okehiet o!/ Dab SfRv-en ( ) <br /> Address Phone Number Street Address,City,State,Zip Code <br /> (� ) 3700 W. Pdry- Are• 970 -S/ouxCa//S S./ 57106 <br /> I,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> Plumber Signaturep Previous Plumber Name(if changed) <br /> y`-K-�teuO� <br /> Plumber Address Previous Plumber address <br /> .4-7-7m0 #,,y 3s'websf�r c✓SS 893 <br /> MPIMPRSW Number Phone Number MP/MPRSW Number Phone Number <br /> Issuing Agent Signature Date Approved <br /> SBD-6399(R.4/99) <br />