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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 /> I North <br /> y - <br /> e- 0 <br /> otb-r ?uk(NNe <br /> (.1..,6 Okilyti <br /> 3—/ <br /> Certification <br /> I hereby certify the system/w��asabandone i accorda ce with Minn. R. 7080.25 and any to al requirements. <br /> ) <br /> Name(please print): lb r k- Title: 'I2CS/ 1— <br /> Address: /076-51 <br /> City: �j�..Q/vCa(J c f.� State: 0 / Zip: 5,j 4( <br /> Phone: 7Ze3 — fO -'ere 2_ Ase: #if aip144 0/9-2�Date: / � Signature: <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-wwists4-03 • 11/21/08 Page 2 of 2 <br />