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of <br /> State tment ofC n SANITARY PERMIT County <br /> De artment of Commerce <br /> Safety and Buildings Division <br /> Integrated Services Bureau Transfer/Renewal Uniform Permit Number <br /> Personal information you provide may be used for seconds purposes[Privacy Law, s. 15.04(1)(m)). 2 O <br /> Permit Renewal Date Permil Transfer Date Original Permit Issuance Date State Regulated Object <br /> I- Z9-o2 -ZS-ECS <br /> Property Location ��//� own ❑ Village I City of <br /> 1/4 1/4,S4G ,T -,:;q N.R 1d E(o W <br /> Lot Number Block Number Subdivision Name Neare oa Lake or Landmark <br /> 9 � . pig s WA.1 <br /> PREVIOUS SANITARY PERMIT HOLDER— IF CHANGED: SANITARY PERMIT TRANSFERRED TO <br /> Name(Please Print) Signature Name(Please Print) Phone Number <br /> Address Phone Number Street Address,City,State,Zip Code <br /> I,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> Plumber Signature Previous Plumber Name(if changed) <br /> Plumbe Address <br /> Previous Plumber address <br /> 17740 3s WIM W1. 5*0 <br /> MPIMPRSW Number IPhone Number MPIMPRSW Number Phone Number <br /> Issuing Agent Signature Date Approved o 1 6 <br /> SBD-6399(R.4199) <br />