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75 <br /> 'Wisconsin Department of Industry, SANITARY �ERMIT County <br /> Labor and Human Relations <br /> Transfer / Renewal <br /> Safety and Buildings Division (PLB 67-T) Uniform Permit Number <br /> Bureau of Building Water Systems 9 75- <br /> Personal Information you provide may be used for secondary pur oses[Privacy Act,s. 15.04 1 m . <br /> Permit ene al Date Permit Transfer Date Original Permit Issuan a Date State Plan ID Number <br /> Prop rty Location l'' 'Town ❑Village [:]City of: <br /> 004 <br /> 1/4 NIP 1/4,S T �© N,R �e W ' <br /> Lot Number Block Number Su division Name Nearest Road, Lake or Landmark <br /> 1 7 <br /> PREVIOUS SANITARY PERMIT HOLDER-IF CHANGED: SANITARY PERMIT TRANSFERRE O: <br /> Name(print) Signature Name(print) Phone Number <br /> Address Phone Number Address <br /> 1,the undersigned,assume responsibility for installation of the private sewage system that has been previously approved for this property. <br /> Plu r S gnature Previous Plumber Na (if changed) <br /> PI be ddre Previous Plum r Address <br /> MP PRSW Number Phone Number MP/MPRSW Number Phone Number <br /> a 4/ 7 <br /> r <br /> Issuing Agent Signature c Date Approved `3 <br /> SBDW-6399(R.04/95) Distribution:Ori al-County; Cop Bureau of Building Water Systems; Copy-Owner; Copy-plumber <br />