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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 ` T North <br />3� <br />Oft <br />60 <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): Kevin Bursch Title: President <br />Address: PO Box 55 <br />City: Hanover <br />Phone: 612-221-1 <br />Date: 9/20/2024 <br />Signature: <br />State: Mn <br />License # if applicable): L2424 <br />Zip: 55341 <br />vdww.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 Page 2 of 1 <br />