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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health No. 23196 <br /> FEE $1.00 P.O-Box 309 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued 'W12/7" <br /> Tank Size 75 gal. <br /> STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. x 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 /> ;enedict Trutwin 501 C.riffitit St., Fit. Paul, HN 551]6 <br /> Location(Legal Description) of Property Where Tank Will be Installed County <br /> NE %E SEI723 T4rJN R15W PtS JACKS-IN I11 Viking Ilill-Vnya,ier Village <br /> {it1Fn@tt <br /> Plumber's Name License No. Address <br /> Ronald Proffit IIPRSW 03072 Dairyl�nd, ',41 54f+30 <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Dairylawl, W1 54 :30 <br /> Address of Issuing Agent (Town, Village,City) Coppt <br /> es:;tcr, "1 54393 :,uinAt <br /> Title: Signature <br /> Zanifr:� rutaiinistrattlr <br />