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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES Division of Health NO. 09284 <br /> FEE $1.00 P.O.Box 309 <br /> (1 Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued . <br /> Tank Size 750 gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. = This permit is for purchase of septic tank only and does (White)-Property Owner <br /> t installation from state or local approval (Pink)-Tank Retailer <br /> not exempt Pp (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> 4 GREM JGH S(* DAM= <br /> Location(Legal Description) of Property Where Tank Will be Installed County <br /> WV o <br /> Plumber's Name License No. Address <br /> UMMA1Mw VI OW 5030 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> r � W1 <br /> Address of Issuing Agent(Town, Village,City) County <br /> WI 3" <br /> Title: Signature <br />