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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 />NeLxrocrkJ <br />fv5` Ill <br />11�f'' f19 <br />130 /38` <br />Certification <br />r.:nN <br />I hereby certify the system was abandoned in accordance with Minn. R. 7080, 2500 and any local requirements. <br />James Braegelmann (Elmer J. Peterson <br />Name (please print): CCU_ Title: Owner <br />Address: 5921 Dague Ave. SE <br />City: Delano State: MN Zip: 55328 _ <br />Phone: 763-972-2420 License # if applicable): 219 <br />L- <br />Date: r - t � - ,; �} 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 • 11121108 Page 2 of 2 <br />