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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 />Certification <br />i hereby certify the sys <br />Name (please print): . <br />Address: <br />City: f <br />Phone: <br />Date: 11 1,2 �! <br />was <br />N- <br />REMOVE EX-m-n I 6US-DRIVEWAY <br />_ZG <br />• j <br />4 0wSH EE-X-+0pUSl <br />APACE-. \ <br />REMOVE tkISTING UTILITY$ERVIC�S <br />COORDINATE 1t103H UTItiITY OW MERS <br />in accordance with Minn. R. 7080.2500 and any local requirements. <br />eAfl (V(XW— Title: j)_ <br />Signature: <br />State: Zip: <br /># if applicable): 111 <br />www.pca.state.mn.us • 651.296-6300 • 800-657-3864 TrY 651.282-5332 or 900-657-3864 Available in alternative formats <br />wq-WWlsts4.03 • 11121108 Page 2 of 2 <br />