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t cO PY II II 11111111 II I I I IIII111 II <br /> • * 4434494 1 * <br /> PRIVATE ONSITE WASTEWATER TREATMENT DANE COUNTY <br /> ' SYSTEM COVENANT: ADDITION/REMODELING REGISTER OF DEEDS <br /> �o R� DOCUMENT # <br /> This covenant is between (2/� 4434494 <br /> grantors,and the County of Dane,regarding the private onsite wastewater 05/27/2008 10:40AM <br /> treatment system(POWTS on the following described parcel(s)located in the <br /> Town of t3 Tf Cy4'ZAY,� Exempt #: <br /> � 11 <br /> in the N quarter of Section /7 ,T N,R 1/ E. Rec. Fee: 11.00 <br /> Pages: 1 <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 a••ress <br /> --fl wt LQf (eA) <br /> C5M 3070 7 VS' Lf <br /> (.., vt P a_iM t2 t i,-) <br /> • Tax Parcel#0 Y L-.- TAWAr:1,'' <br /> I(We)the undersigned are applying for a building permit for a repair,alteration, or addition to the • ocated on <br /> the above referenced property that will involve 25%or more of the existing living space or th dition of 1 bedroo r for <br /> a replacement structure. This construction is intended to accommodate existing family members o y. <br /> In compliance with the requirements Dane County Code ch.46,or acts amendatory thereto,this affidavit is to <br /> acknowledge that the existing POWTS(is is not ized in accordance with the current regulations for the waste. •ter load <br /> generated by the building served by the sys em after this work is finished. This is also to acknowledge that th- (is not) <br /> 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 /> ;44 4 ACKNOWLEDGEMENT <br /> x f L% /i ----- <br /> Owner Name(Signature) Owner Name(Signature) <br /> Owner Name(Print) Owner Name(Print) <br /> STATE OF WISCONSIN ) <br /> ) ss. <br /> COUNTY OF DANE ) <br /> Personally came before me this d.� day of G.NC\n — -4'9-a 6 a the above named person(s) <br /> to me known to be the persons who executed the foregoing instrument and acltowledged the same. <br /> 111•• . O. c(N G.c �I '�c <br /> Notary Public sue County,Wis sin 11ry1 O <br /> My Commission ist_***_anent. (If not,expiration date is I <br /> Dane County Environmental Health 5/01 <br /> r <br />