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PLB. 62, <br />FEE $1.00 <br />(1 Permit per Tank) <br />Date Issued 611V74 <br />Tank Size 1200 gal. <br />Private Res. Z <br />Public <br />DEPARTMENT OF'HEALT14 AND SOCIAL SERVICES <br />Oivision of Health <br />P.O. Box 309 <br />Madison, Wisconsin 53701 <br />STATE SEPTIC TANK PERMIT <br />This permit is for purchase of spetic tank only and does <br />not exempt installation from state or local approval <br />and/or permits. <br />NO. * + <br />Copies: <br />(White) -Property Owner <br />(Blue) -Tank Retailer <br />(Canary) -Division of Health <br />(Pink) -Issuing Agent <br />Owner's Name Owner's Address <br />THEICIDIM Sism 1211U, It, CO. Rd B St, Pain. DIX <br />Location (Legal Description) of Property Where Tank Will be Installed County <br />GIN WM 2*3 3=3 T410Wit JACSSQY <br />Plumber's Na��mppe*��� �/t gn}y� License <br />� No. Add;;X. <br />T <br />5421 <br />Signature of Person Obtaining Permit Address if Other Than Owner <br />Address of Issuing Agent (Town, Village, City) County <br />WI 54M BMUGM <br />Title:I Signature <br />Z0X= <br />