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I'M 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health <br /> FEE $1.00 P.O.Box 309 NO. 15633 <br /> (1 Permit peOV Madison,Wisconsin 53701 <br /> Date Issued <br /> 2400 <br /> Tank Size gal. <br /> STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. This permit is for purchase of septic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> (eiue)- )-i sion of gHealth <br /> Public and/or permits. (Canary)-issuing Agent <br /> Owner's Name Owner's Address <br /> Hi4laven Resoft DaWxAZ': JI W30 <br /> Location(Legal Description) of Property Where Tank Will be Installed Tz <br /> Xw U spa 20 R164 <br /> Plumber's Name License No. Address <br /> Rod HoyU= $ w �Q iebst+sr, WI <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> Address of Issuing Agent <br /> f(Town,Village,City) County <br /> 4eb1�Z WI 5sWBuillett <br /> Title: Signature <br />