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POWTS AGREEMENT <br /> Document b Document Tille <br /> 2015SE? 10 a 11: 2 I <br /> This agreement is made between: ( f Pc't( <br /> and the County <br /> of Dane regarding the Privaje Onsite Wastewater Treatment System(POWTS) . <br /> located the Town of: ( £ve .-- <br /> In the S 41 1/4 of the W 1 of Section '21 T. '' N.,R. 7 ( <br /> Specifically:(Type or neatly print the complete legal description of your property <br /> in the space below. The legal description is on your deed and usually on your tax <br /> bill.) <br /> Recording Gformnation: <br /> j r <br /> Your Name and Return Address: <br /> \b 0,4,,,. k A.-11,,I P_ et <br /> 910P -rh e.i 5 a <br /> N r ,ow,...�-i i4 53 ,,,,,„ 1 <br /> mgi010? 031 —1PS-0 <br /> Tax Parcel Number <br /> At the above named location (I)❑(We),plan to(check all that apply): <br /> Build a house addition or remodel an existing house resulting in an Increase in bedrooms/wastewater, <br /> Build a replacement residence or additional structure and connect it to an existing POWTS, <br /> Build an Additional Structure and connect It to an existing POWTS. <br /> The existing POWTS has been determined to be in compliance with bedrock and groundwater standards contained in Wisconsin <br /> Administrative Code(COMM83).VI(I)0(We)understand that the sizing determination of the existing POWTS is being based on <br /> the number of people living in the house in lieu of total bedrooms.The total number of people utilizing the existing POWTS will be ' <br /> _9__people. <br /> • <br /> .4, /-7 -"'' <br /> 01,511111P" Mr;jr, iiiiip. <br /> •wner's Signature <br /> p`9- ,�.'' • <br /> A?-ze).ci- ' <br /> Date <br /> 0 p,4ga,Ubpeyr <br /> Subscribed and sworn to before me Q;.• ..,:17),s,, <br /> This cl'*` day of &cA,20 15 r / �OTA� ,� 1 <br /> A- d <br /> N to Publi i Z ".' 1 <br /> A A('€.County,Wisconsin tz� . A(/8 LAG ,I ai <br /> My Commission Expires k t—I s"9J,,•.� ,.. <br /> I% t. ......• •` <br /> O O�, <br /> 9/4/10lS•DocumentI:This Instrument Dratted by Public Health-Madison it Dm County <br />