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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Jiviti6n c NO. <br /> f Health 2148.E <br /> FEE $1.00 P.O.Box 309 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued ROy.]A 1975 <br /> Tank Size 750 _gal. STATE SEPTIC TANK PERMIT <br /> copies: <br /> Private Res. Z This permit is for purchase of septic tank only and does (white)-Property Owner <br /> (Pink)-Tank Retailer <br /> not exempt installation from state or local approval (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> 630 # Uvw Wks IT <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumber's Name License No. Address q <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> WI 5 <br /> Address of Issuing Agent (Town, Village,City) County <br /> Title: Signature <br />