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Wisconsin Department of Industry, INSPECTION <br /> Labor and Human Relations <br /> Safety&Buildings Division REPORT <br /> Bureau of Building Water Systems (V�Q f� ?�L' <br /> Inspection Date el <br /> / (�" f-6� f T �A <br /> Name of Premises Address or Legal Description (/ 1 `�' City/Township County <br /> Master Plumber Name and Address Master Plumber Firm Name and Address Plan I.D.No. <br /> Sanitary Permit No. <br /> Journeyman Plumber/Soil Tester Licensed Person's Name(s)and License Number(s) <br /> Owner's Name and Address <br /> tC Qt} �r <br /> X770 j <br /> 1 <br /> Qr'"E _ <br /> s <br /> x <br /> Page of Signature of Responsible Licen d Perso ( nly one needed) <br /> Check all Signature of Plumbing Consultant/Private Sewage Consultant <br /> Original: Copiesto: thatapply <br />