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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health NO. <br /> P.O.Box 309 <br /> FEE $10.00 Madison,Wisconsin 53701 <br /> (1 Permit per Tank) <br /> Date Issued <br /> Tank Size gal. STATE SEPTIC TANK PERMIT Copies: <br /> (White)-Property Owner <br /> This permit is for purchase of septic tank only and does (Pink)-Tank Retailer <br /> Private Res. approval not exempt installation from state or local app (Blue)-Division of Health <br /> and/or permits. (Canary)-Issuing Agent <br /> Public <br /> Owner's Address <br /> Owner's Name <br /> Location (Legal Description) of Property Where Tank Will be Installed <br /> County <br /> 'I Plumber's Name <br /> License No. Address <br /> Signature of Person Obtaining Permit <br /> Address if Other Than Owner <br /> County <br /> Address of Issuing Agent(Town,Village,City) <br /> Title: Signature <br /> I <br />