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PLR. 68 j` DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> _ Division of Hea309 NO 35644 <br /> PCC $L00 P.O.Box 309 <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Dme Issued <br /> 'Tank STATE SEPTIC TANK PERMIT <br /> Co01<S: <br /> Private Res. This permit is for purchase of septic tank only and does (Wbue1-Property owns. <br /> tnink)Tank r elaller <br /> not exempt installation from state or local approval lamep Division or Health <br /> Public arM/or permits. Icanaryl lssumn anon <br /> Owner.Name Owner.Addrer: <br /> Loeetion(Legal De,nption) of Proper, Where Turk Will he Installed County <br /> I" 1.11 I/(.r! ��[ i,— %.." / �/l//i"�/%I�' �i�i F /.•' %! :"/� �J/./i. " ir��� <br /> Plumbers NamcLicense Uo. - Address <br /> Signature of Person Obtaining Permit / Address it Othea'Ihas Owner' ' <br /> Address of Issuing Agent (Tow'., Village.City) _ ) County <br /> 'Title: Signelurc /I! j <br />