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PLB. 68 <br />FEE $10.00 <br />0 Permit per Tank) <br />Date Issued <br />Tank Size -.L <br />( -`gal. <br />Private Res. ' <br />Public <br />DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br />Division of Health NO. <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 />(Pink) -Tank Retailer <br />not exempt installation from state or local approval (Blue) -Division of Health <br />and/or permits. (Canary) -Issuing Agent <br />Owner's Name <br />Owner's Address <br />Location (Legal Description) of Property. Where Tank Will be Installed <br />County <br />Plumber's Name <br />license No. <br />Address <br />Signature of Person Obtaining Permit <br />Address if Other Than Owner._., <br />Address of Issuing Agent (Town, Village, City) <br />Count <br />Title: <br />Signature <br />