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� � <br /> 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 /> ���� �� �- <br /> � ����� . <br /> , <br /> ��,� � � <br /> F�� <br /> Certification <br /> 1 hereby ceriify the system was abandoned i accordance with Minn.R. 7080.2500 and any! al r�quirements. <br /> Name(please p�nt): Glen Kothrade �� �(►�, ,� TUe: President ����yn� <br /> Address: 12059 Whitetail Ln <br /> �;ty; Hanover g�te; MN Z;p: 55341 <br /> Phone: 763.498.8702 l.icense#if applicable): ��92 <br /> Date: �Z—�t— 1 lP Signature: �� -'�G Sc�Q �' <br /> ��� / _� /� A <br /> _ l�i��%�-�'�%l�.,e�� —' l�C9� �O 'r � � <br /> _. �' S� � � <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-wwlsts4-03 • i!l21/08 Page 2 of 2 <br />