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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br />Divisior ,s Health <br />FEE $10. 00 P.O. Bax 309 <br />(I Permit per Tank) Madison, Wisconsin 53701 <br />Date Issued 6/23%7Fs <br />Tank Size 7 5 D gal. <br />STATE SEPTIC TANK PERMIT <br />Private Rest This permit is for purchase of septic tank only and does <br />not exempt installation from state or local approval <br />Public and/or permits. <br />NO. 5537 <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 />t2 <br />`ri 1'+♦ = ifi%�" <br />.. <br />23 <br />a; `sJ Jcc ffrr Fsor° st.. 55418 <br />Location (Legal Description) of Property, Where Tank Will be Installed <br />County <br />.:are NIZ S r-14 �40,, R15W JAC'FSa <br />nt t <br />Plumber's Name <br />Lic`e�ynfse No.03072 <br />Address <br />Pa3 M fit <br />lJ of <br />,i q <br />T { ) ( ry <br />Signature of Person Obtaining Permit ; } <br />r <br />Address if Other Than Owner <br />.t' <br />Address of Issuing Agent (Town, Village, City) i <br />County <br />'' eb-3ter =i 54493 <br />4 <br />Title: <br />Signature <br />:tonit g aaj:lstrtiaoY <br />