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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health <br /> FEE $10.00 P.O.Box 309 NO. 14002 <br /> (1 Permit per TanMadison,Wisconsin 53701 <br /> Date Issued-8/3/78 <br /> Tank SiA200 gal. <br /> 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 (BlRetailer <br /> (Blue)-Division <br /> )-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> Wvid EIggers .,rq,4)Sterr WI 54893 <br /> Location(Legal Description) of Property.Where Tank Will be Installed County <br /> S17 SE SEL-23 T41YIN R15'o. • .. <br /> Burnett <br /> Plumber's Name License No. Address <br /> rvyierick 1opkins )3059 : ter, ..T 54893 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> c bstt?r. Vil 54d93 <br /> Address of Issuing Agent(Town,Village,City) County <br /> E+iebetW, WI 5#893 3urnPtt. <br /> Title: Signature <br /> Zminq Af3 dnistrator <br />