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III C II it <br /> Ii <br /> II <br /> 11 11 <br /> 9036896 <br /> Tx:8789732 <br /> POWTS AGREEMENT <br /> Document it Document Title KRISTI CHLEBOWSKI <br /> DANE COUNTY <br /> This agreement is made between: K'ivte.3 * (41 4- '4wtcc:kb REGISTER OF DEEDS <br /> J and the County <br /> of Dane regarding the Private Onsite Wastewater Treatment System(POWTS) DOCUMENT # <br /> located in the Town of:Bristol 5260897 <br /> In the SE 1!4 of the NW 1/4 of Section 29 T.9 N.,R. 11 E. <br /> Specifically: (Type or neatly print the complete legal description of your property 08/22/2016 12:31 PM <br /> in the space below. The legal description is on your deed and usually on your tax Trans. Fee: <br /> bill) Exempt#: <br /> Rec. Fee: 30.00 <br /> Pages: 2 <br /> Recording Information: <br /> Lot 33 of Moonlight Circle Subdivision. <br /> Address=6781 Moonlight Circle. <br /> Parcel Number 0911-292-7023-6 Your Name and Return Address: <br /> $è115 4 LOold f- .P,e4stc J i`, <br /> .S2( CI✓.s.w1ercio I Ave. <br /> $u K }Pta.rre w= 535,D <br /> Tax Parcel Number <br /> At the above named location®(1)❑(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 utilizing the existing POWTS will be <br /> people. <br /> i 4if i , <br /> t J / .- i . <br /> V <br /> Owner's Signature <br /> , eji sg)//C <br /> Date <br /> i <br /> Subscribed and swo to before me <br /> ' 4i day of ,20 (‘o I, <br /> Notary Public < row L Qu.vv,e`. <br /> &OE County,Wisconsin ^^�� <br /> My Commission Expires /I-Ot it-ao 17 <br /> i <br /> • <br /> $/1$12016-Document l This Instrument Drafted by Public Health-Madison&Dane County <br />