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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 /> /403 a <br /> %*-77/. <br /> D111k fp`r`(v\P <br /> e.,61)Ailyej <br /> 3-0)0 <br /> Certification <br /> I hereby certify the system was abandons r accords ce with Minn. R. 7080.25,,and any to al requirements. <br /> Name(please print): a )6,\ O 2/ Title: T I2eS/d evi <br /> Address: /426,51 (,,cJkc'r6 ( 1—/t/ <br /> City: 441..&/t_2— State: /44. Zip: S 5 cJ( <br /> Phone: „ ./' 7s r3 ” fes 9?) 2— L' # <br /> Date: A-0/ Signature: / j �.. A' <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•wwrsts4.03 • 11121108 Page 2 of 2 <br />