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I IllIllIlli 11111 III <br /> POWTS AGREEMENT 9 17262 6 <br /> Document it Document Title <br /> KRISTI CHLEBOWSKI <br /> This agreement is made between: •4Q- DANE COUNTY <br /> and the County REGISTER OF DEEDS <br /> of Dane regarding the Pri ate On 'te Wiastewater Treatment System(POWTS) <br /> located in the Town of: Pliny K+•1liC DOCUMENT # <br /> • <br /> In theM.f/1/4 of the f/6V 1/4 of Section 7 T. 0. N.,R. t'1 E. 5289117 <br /> Specifically: (Type or neatly print the complete legal description ofyour property 12/02/2016 3:57 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: 1 <br /> p1 i 057r -o 7Z _%cam / Recording Information: <br /> joetorie Q t t Your Name and Return Address: <br /> 1.011- j 4V:, CS!? 6,564i P 7-1/1 I t uv - <br /> $4— <br /> c$'/—o7Z-9c,qs-,6 <br /> Tax Parcel Number <br /> At the above named location)(I)❑(We),plan to(check all that apply): <br /> 161.., <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 /> 0 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).J]Zy(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 /> .13_people. <br /> Di r � UT:A,- <br /> P 1 N& RAJ <br /> Owner's Signature <br /> U/2 ( / 2-t; I6. <br /> Date <br /> Sub nbed and sworn to before me <br /> . of. 1V 21 <br /> a*'►dcounty,Wisc• <br /> My Commission F.x_p 6W <br /> I VI B/2o16-Doamentl:This Instrument Drafted by Public Health-Madison&Dane County <br /> Q) <br />