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PLD.' 8 <br />FEE $10.00 <br />(I Permit per Tank) <br />Date Issued 4/21/60 <br />Tank Size 750 gal. <br />Private Res. X <br />Public <br />DEPARTMENT OP HEALTH AND SOCIAL SERVICES <br />Division of Health NO . 20113 <br />P.O. Box 309 <br />Madison, Wisconsin 53701 <br />STATE SEPTIC TANK PERMIT <br />Copies: <br />This permit is for purchase of septic tank only and does (White) -Property Owner <br />not exempt installation from state or local approval (Pink) -Tank Retailer <br />(Blue) -Division of Health <br />and/or permits. (Canary) -Issuing Agent <br />Owner's Name Owner's Address <br />Lawrence r E. T ; ; l ox 70F S.i.rcn, !;-d <br />Location (Legal Description)) of Property Where Tank Will be Installed <br />County <br />SE SE .".'a C i I£�{ � 11 T4 O N 1 u 6 t`t <br />t3tai�2iett <br />Plumber's Name <br />License No. <br />Address <br />Thams Stusek <br />71P 6056 <br />;;ebster <br />Signature of Person Obtaining Permit <br />Address if Other Than Owner <br />w'ebster <br />Address of Issuing Agent (Town! Villag , City) <br />County <br />"iebster __ <br />:iumett <br />Title: <br />Signature <br />Zoni' r, Administr—ator <br />