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V <br /> AFFIDAVIT OF OWNER NOTIFICATION RELATING TO POWYS MANAGEMENT PLAN <br /> Owner Nvnc Parcel Number <br /> Mary Srfatz <br /> Owner Address (City, Slate,Zip) <br /> Si t2 Rcj. Goss as rst w► r'�:� <br /> Property Location <br /> NV /4 NW V. See.olp T 9 N I. g E Townshin ffe*4�ul D20, <br /> Subdivision/CSM Lot Block <br /> FAILM -' — <br /> TYPE OF SYSTEM: MOttrIc1 <br /> 1, tea/s1 Mcr cIL , LICENSE it ,22D"'S 1)O HEREBY •. <br /> VERIFY TTIAT I DAVE DELIVERED A COPY OF TILE MANAGEMENT PLAN ON FILE WITH TILE DANE <br /> COUNTY HUMAN SERVICES DEPARTMENT, PUBLIC HEALTH DIVISION, ENVIRONMENTAL <br /> 1-IEALT1I SECTION, FOR TILE PRIVATE ONSITE WASTEWATER TREATMENT SYsTEl1I (POWTS) <br /> NAMED ON Tills DOCUMENT,TO TILE OWNER REFERENCED ABOVE. TILE POWTS DESIGN FOR <br /> TILE SANITARY PERMIT APPLICATION TIEING SUBMITTED IIAS TILL SAME INFLUENT/EFFLUENT <br /> QUANTITIES AND QUALITIES AS INDICATED ON TILE MANAGEMENT PLAN, AND ALL <br /> COMPONENTS IN T ilE DESIGN ARE INCLUDED IN THE MANAGEMENT PLAN. <br /> . 6--4-Di <br /> Plumber Signature Date <br /> M urea./ I tnhOl z <br /> Plumber Name (Print) <br /> Plan r/ Yed by <br /> XiLi4,/tr <br /> Sanitari to <br /> Date <br />