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PLB. 68 <br />FEE $1.00 <br />(1 Permit per Tank) <br />Date Issued <br />Tank Size gal. <br />Private Res. ,4 " <br />Public <br />DEPARTMENT OF HEALTH AND 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. 21455 <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 />/q/V,r/ <br />Location(LegalDescription) of Property Where Tank Will be Installed <br />County <br />Plumber's Name <br />License No. <br />Address <br />} <br />Z . <br />Signatu.W- - Plsison`OeMning Permit; <br />Address if Other Than Owner <br />Address of Issuing A t (Town, Village, City) <br />County <br />t �`,• <br />' w 17 4 <br />Title: <br />Signature <br />