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AFFIDAVIT - PER CAPITA FLOW STATEMENT <br />Private On-site Wastewater Treatment System (POWTS) <br />Sizing based on Occupants <br />USE 13LACK INK ONLY 1 Date: r7 / / /,1-e / ? -- <br />Governmental Unit: <br />Burnett County Land <br />Management Department <br />Legal Land Description: <br />owner(s): <br />RYAN HARTOS & MENG CHF <br />Parcel No.: 034 -- 1529 — 02 - 000 <br />ti GIDW. LIDT 2 > S29, T37N, R18W, Town of Trade Lake, Burnett County <br />Wisconsin. SSM#.1730 wt 1 ova o epi 1 � :/ol.q � ��. 13G �� <br />io-7-r-7 <br />Name and Return Address: <br />Burnett County Land Management Department <br />Courthouse <br />Siren, WI <br />This document is recorded to acknowledge that the proposed POW I'S (a.k.a septic system) on this parcel located at <br />this address: 20760 Cedar Point Road, Cn•antsburg, Wl is being sized for _3_ bedrooms X <br />150 gallons per bedroom = _450_ gallons per day. Based on the sizing, this POWTS is code compliant for _6_ <br />people (divide gallons per day by 75 to get the number of people). I/We also plan to modify the total number of bedrooms <br />for the structure to more than 3 bedrooms. I/We will disclose this information to any parties interested in purchasing this <br />property in the future. Plans for the POWTS will be on file in the Burnett County Land Management Department. This <br />affidavit is entered to inform any subsequent owners of the limitations attached to this property. The following shall <br />apply: <br />1. The owner of this property is responsible for the operation and maintenance of this POWTS. <br />2. This Agreement is binding upon the Owner and his/her heirs, successors, and assigns. The Owner shall have this <br />Agreement filed and recorded with the Burnett County Register of Deeds in a manner which will permit the existence <br />of the Agreement to be determined by reference to the Property containing the POWTS. <br />3. This Agreement will remain in effect until Gov tal Unit, which is responsible for issuance of POWTS sanitary <br />petrnits, certifies that this restriction is no longer r cl rec or ?Ian the POWTS was replaced or increased in size. <br />Approved by Governmental Official Name, Title: Z " 4� Ul} yJ 5 LV DP�le Date_f IL - <br />Owner's Signature (Notarized) <br />Owner's Printed Name <br />STATE OF WISCONSIN <br />COUNTY Of >v r i\k .� } SS <br />This document w s signed before me on this G` clay of 4u �u s t 20 1 Y by fZy atn t4 --t- C to s <br />CE- U., who personally appeared before me, known to be the person who subscribed his/her name hereto. <br />Notary <br />Public rinted) <br />Notary Public (signature) <br />My commission (is) (expires) la t` /a- I <br />(NOTARY'S SE,,U,,) <br />ANN SCJJAEFEFt LANE <br />ta01WW 1h <br />Dratted by: Mary Jo Huppert Personal information you provide may be used for sccon <br />da'S' PIrl '�s (Privacy Law. s.15.04t Ixm)1 <br />