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IU 1 <br /> l llllllI1Ifl1IflIfl l <br /> POWTS AGREEMENT I 8990767 <br /> Tx:8758654 <br /> Document# Document Title <br /> KRISTI CHLEBOWSKI <br /> DANE COUNTY <br /> This agreement is made between:Peter Nasett <br /> and the County REGISTER OF DEEDS <br /> of Dane regarding the Private Onsite Wastewater Treatment System(POWTS) <br /> located in the Town of Medina • DOCUMENT # <br /> In the SW 1/4 of the SW 1/4 of Section 16 T. 8 N.,R. 12 E. 5231ENT <br /> Specifically: (Type or neatly print the complete legal description ofyour property 05/52316 12 PM <br /> in the space below. The legal description is on your deed and usually on your tax Trans.201 Fee: <br /> bill) Exempt#: <br /> Rec. Fee: 30.00 <br /> • Pages: 1 <br /> • Recording Information: <br /> Parcel Number 0812-163-9300-2 <br /> . <br /> House located at 5555 Oak Park Rd Your Name and Return Address:f TEE- /,/PSSTT <br /> LOT 1 cS m (5 29 SSSS o4t� Prvete-RtO <br /> peli4e-S fMi -, w 1 5--;6-5-1 <br /> T7 <br /> i <br /> c /Z-lb3-9&0o ~2 <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).®(I)❑(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 utilizin the existing POWTS will be 3 <br /> people. <br /> Owner's Signature <br /> S in"-1 I/ b i <br /> Date <br /> Subscribed and sworn to before me <br /> Thi L ' day of y 20 Ito <br /> I WI _1 �W . <br /> Notary Publi �O ti h J. See-��c r - - _ <br /> County,Wisconsin <br /> My Commission Expires a—a& a n D..0 - _ - <br /> I <br /> ----------..--,--__ _ <br /> 5/4!2016-Documeotl:This Instrument Dulled by Public Health-Madison&Dane County <br /> ..____________.-------_____---- Cl......... <br />