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Map <br /> Include location of building sewer, septic tank(s), soil dispersal system, cesspools,seepage pits, and other pits. Also <br /> include a permanent reference point(s) and dimensions. <br /> T North <br /> � <br /> � <br /> �P <br /> r <br /> ��c���5 <br /> ; � � <br /> � <br /> f r�o�� <br /> �_---- <br /> Certification <br /> !hereby certify the system was abandoned in accordance with Minn.R. 7080.2500 and any local requirements. <br /> Name(please print): Glen Kothrade Tt1e; President <br /> Address: 12059 Whitetail Ln <br /> ��ty; Hanover __ State: MN Zip: _55341 ` <br /> Phone: 763.498.8702 L' e#' i I ): �92 <br /> Date: (,Q '�"(, Signature: <br /> www.pca.state.mn.us • 651-296•6300 • 800-657-3864 • TTY 651-282•5332 or 800•657-3864 • Available in alternative formats <br /> wq-wwists4•03 • 11/21/08 Poge 2 of 1 <br />