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PLB. 68 <br />FEE S 1.00 <br />(1 Permit per Tank) <br />Date Issued <br />Tank Size gal. <br />Private Res. <br />Public <br />DEPARTMENT OF HEALTH (XND SOCIAL SERVICES <br />= Division of Health <br />P.O. Box 309 <br />Madison, Wisconsin 53701 <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 />NO. 35609 <br />Copies: <br />(White) -Property Owner <br />(Pink) -Tank Retailer <br />(Blue) -Division of Health <br />(Canary) -Issuing Agent <br />Owner's Name Owner's Address <br />Location (Legal Description) of Property Where Tank Will be Installed County <br />Plumber's Name <br />License No. <br />Address <br />Signaturef of Pason Obfaining Permit <br />Address if Other Than Owner <br />Address of Issuing Agent (Town, Village, City) <br />County <br />Title: <br />Signature <br />i <br />