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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 />Q� <br />0 D we u <br />v� <br />oA <br />\41 <br />Certification Certification <br />i hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements. <br />Name (please print): / Guc/ WA'-t-(L'(Title:- <br />Address: 15 o g b o1'Lo C f S <br />City: cu'� Stater Zip: S�S� J <br />Phone: -7&� - (, Z - U 7 License # if applicable): _� % ! L/ <br />Date: Y Signature: — �G---� <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 • 11121108 Page 2 of 2 <br />