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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 />U <br />E <br />E7 <br />fl <br />I <br />Certification <br />1 hereby certify the system was abandoned in a oordance with Minn. R. 7080.2500 and any local requirements. <br />Name (please print): o A Q Title: <br />Address: `� U CA;j V1 I U -V-)Y IJ 19AV t <br />City: J 1� _ State: Zip: 3 S <br />Phone: i� - 22�' �(7 1 ` License # if pplicable): <br />Date: t. '-U t 1( 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 />