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• <br /> PRIVATE ONSITE WASTEWATER TREATMENT <br /> SYSTEM COVENANT: ADDITION/REMODELING <br /> This covenant is between v 1 `� ��dmh �o 2014 JUL -8 f;1'1 10: I I <br /> • <br /> grantors,and the County of Dane,regarding the private onsite wastewater <br /> treatment system(POWTS)on the following described parcel(s)located in the <br /> Town of t0DLet <br /> in the isit quarter of Section 19 ,T 07 N,R OR E. <br /> Type or neatly print the legal description of your property in the space below. If <br /> you need more space, use the reverse side or attach a copy of the deed) Record this document with the Register of Deeds <br /> Your name and return address <br /> • <br /> . JK aVIIST �ST9t1 � LaY ;7 1 EW'IQ S'er4ePR <br /> -7 <br /> -7 6 1 &i n-t m crELO rJ' v E <br /> i-V 2civA <br /> ®' Tax Parcel#03g 070 7 -i 1 2113`0 <br /> I(We)the undersigned are applying for a building permit for a repair,alteration or addition to the dwelling located on <br /> the above referenced property that will involve 25%or more of the existing living space or the addition of 1 bedroom. <br /> This construction is intended to accommodate existing family members only. <br /> In compliance with the requirements Dane County Code ch.46, or acts amendatory thereto,this affidavit is to <br /> • <br /> acknowledge that the existing POWTS(is)(is not)sized in accordance with the current regulations for the wastewater load <br /> generated by the building served by the sysfem after this work is finished. This is also to acknowledge that there(is)(is <br /> not)an approved area for the purposes of siting a replacement POWTS on this parcel. <br /> I(We)certify that the existing private sewage system is not failing by causing back-up of sewage into the structure, <br /> discharge of sewage to the ground surface or discharge to a drain tile. I(We)agree to replace the system with a code <br /> complying system when and if any additions or changes to the structure result in additional wastewater load as determined <br /> by definitions or criteria in state and county code,and/or when the system fails as defined in s.145.245 Wis.Stats.,This <br /> agreement is binding upon the owners of the described parcel and his,her or their heirs,successors or assigns. <br /> ACKNOWLEDGEMENT <br /> • <br /> Owner Name(SignatuWr Owner)/ame(Sigy• -) <br /> 4/44,146-r,..j LP') i's04;-1 ,,ce.411 <br /> Owner Name(Print) Owner Name(Print) <br /> STATE OF WISCONSIN ) • <br /> ) ss. <br /> COUNTY OF DANE <br /> Personally came before me this 7+4 day of ,ct�� (ij ,the above named person(s) <br /> to me known to Lc the persons who executed the foregoing instrumend acknowledged the same. <br /> Notary Public Dane County,Wisconsin <br /> My Commission is permanent. (If not,expiration date is 60109//7) <br /> Dane County Environmental-Health 5/01 <br /> • <br /> • <br /> • <br />