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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 />Certification <br />1 hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements. <br />Name (please print): � UE L SC H U T h Title: ►-o v` e Kt o- v� <br />Address: 'I >o 2 -to <br />City: H <br />Phone: °763 - `f 9 g7o L <br />Date: d— l t-7- Z Signature: <br />State: hA A) Zip: 5� 35/f <br />License_# if app jpable): (..I 9Z <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 />