Laserfiche WebLink
PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br />• Division of Health <br />FEE $1.00^ P.O. Box 309 NO. <br />(1 Permit per Tank) Madison, Wisconsin 53701 <br />Date Issued <br />Tank Size75gal. <br />Private Res. Z <br />Public <br />STATE SEPTIC TANK PERMIT <br />This permit is for purchase of septic tank only and does <br />not exempt installation from state or local approval <br />and/or permits. <br />Copies: <br />(White) -Property Owner <br />(Pink) -Tank Retailer <br />(Blue) -Division of Health <br />(Canary) -Issuing Agent <br />Owner's Name <br />Owner's Address <br />FeAve. <br />I= C3AIM9 V1 <br />Location (Legal Description) of Property Where Tank Will be InstalledCounty <br />Plumber's Name <br />License No. <br />Address <br />cmBay= <br />HPf <br />Signature of Person Obtaining Permit <br />'Sam$V1 <br />Address if Other Than Owner <br />J <br />Address of Issuing Agent (Town, Village, City) <br />County <br />Title: <br />Signature <br />. <br />-./ <br />