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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 /> �01'tIl <br /> �i� <br /> k � <br /> � <br /> � ��/ <br /> � <br /> � <br /> � <br /> � <br /> Certification <br /> !hereby certify the system was abandoned in accordance with Minn.R. 7080.2500 and any local requirements. <br /> Name(piease print): Glen Kothrade Title: President <br /> Address: 12059 Whitetail Ln <br /> Ciry: Hanover State: MN Zip: 55341 <br /> phane; 763.498.8702 Li e#if MPCA#0192 <br /> Date: 06-07-2016 Signature: <br /> www.pca.state.mn.us • 651•296-6300 • 800-657-3864 • TTY 651•282-5332 or 800•657-3864 • Available in altemative formats <br /> wq-►wvists4•03 • i f121/08 p°se Z°f Z <br />