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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 /> � <br /> � <br /> ����� <br /> ���� <br /> ��. x .�` <br /> Certification <br /> I hereby certify the system was abandoned in accordance with Minn. R. 7080.2500 and any local requirements. <br /> Name(please print): 1'���'��'� ��►� �7-�( Title: <br /> --___ <br /> - - <br /> -- --__-------- <br /> Address: a � `� � L�z-�f� •.--- l�'• � ° <br /> c�ty: S T ; �l� �c-�-�-�— _�state: �� � z�P: S S-3�� <br /> Phone: �/.1. —�'ri`—u:rl. _ License#if applicable): L 3$ j�3 <br /> Date: � -�% -/` Signature: ,,��s <br /> — --� - <br /> -- - _ _ ----- -------- - __-- --- <br /> www.pca.state.mn.us • 651-296-6300 • 800-657-3864 • TfY 651-282-5332 or 800-657-3864 Availabte in alternative formats <br /> wq-wwists4-03 • 11/11/08 Page 2 of 1 <br />