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AFFIDAVIT OF OWNER NOTIFICATION RELATING TO POWTS MANAGEMENT PLAN <br /> • Owner Name Parcel# <br /> Peter&Jennifer Simon 012.0911_183-0243-0 <br /> Owner Address <br /> 2780 Brooks Ridge Drive, Sun Prairie,WI 53590 <br /> Property Location <br /> NE 1/4 SW 1/4 Sec. 18 T9N R11 E Township/City of Bristol <br /> Subdivision/CSM <br /> Lot 23 Winfield Estates <br /> Type of System: Dosed Gravity In-Ground POWTS <br /> I, i 4' ii :LJV u.'. , LICENSE# 7/-7l DO HEREBY <br /> VERIFY THAT I HAVE DELIVERED A COPY OF THE MANAGEMENT PLAN ON FILE WITH THE DANE <br /> COUNTY HUMAN SERVICES DEPARTMENT,PUBLIC HEALTH DIVISION,ENVIRONMENTAL <br /> HEALTH SECTION,FOR THE PRIVATE ONSITE WASTEWATER TREATMENT SYSTEM(POWTS) <br /> NAMED ON THIS DOCUMENT,TO THE OWNER REFERENCED ABOVE. THE POWYS DESIGN FOR <br /> THE SANITARY PERMIT APPLICATION BEING SUBMITTED HAS THE SAME INFLUENT/EFFLUENT <br /> QUANTITIES AND QUALITIES AS INDICATED ON THE MANAGEMENT PLAN,AND ALL <br /> COMPONENTS IN THE DESIGN ARE INCLUDED IN THE MANAGEMENT PLAN. <br /> Ly//14—C;)k <br /> / 22� s; <br /> Plumber Si nature Dat <br /> L,1.2r4- +I Vor4 <br /> Plumber Name(Print) <br /> Plan reviewed by <br /> /I 3 e3 <br /> Sanitarian Dat <br />