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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> i- Division of Health NO. �� <br /> FEE $1.00 P.O.Box 309 <br /> I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued <br /> Tank Size' gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. This permit is for purchase of spetic tank only and does (white)-Property Owner <br /> (Blue)-Tank Retailer <br /> not exempt installation from state or local approval (Canary)Div inion of Health <br /> Public °� and/or permits. (pink)-Issuing Agent <br /> Owner's Name Owner's Address <br /> r' <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumber's Name License No. Address <br /> Signgture of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent (Town Village,City) County <br /> Title: Signature <br />