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Map <br /> Include location�>fnt refe enCe point(s)'and dimensio s'SRersal system, cesspools, seepage pits, and oth��r pits. Also <br /> inc1ude a permar e <br /> T North <br /> � ��• <br /> /� ;-, <br /> Y <br /> G"���. <br /> �- <br /> , <br /> �r�y����� ,� ' /a, RS <br /> -� �llr�' <br /> I p��to <br /> Certificatior� <br /> 1 hereby certify tne system wss abartdoned in accadance with M►nn.R_7080250U and any loCa►requlrements. <br /> /� JJ !�i �/�t / � d����� <br /> Name(pieasepiint): ! A ��c:�'�' _ Qd'�' �t':) _ TIUe: /tM f <br /> AddfeSs: �i Y/ ���� <br /> r State: /�- Zip: S S 3 7C <br /> S � ,�'!:c/�..��-/ �� ,_..^---- <br /> Ciry: _ — <br /> � /�` �,� ,d��� License#'rf appii ble): � 3 �--� <br /> Phone: � rl_ •��"�" <br /> Date: � - 7 L - � 5 Signature: /�L <br /> ���_�, • 651-296-6300 • 800-657-3864 • TT1'b51-282-5332 or 800-657-3864 • Avaitahle in altemat�e of 2 <br /> wq•wwisrs4-03 � 11/21lOS <br /> ' <br />