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, . - -���a,�.:� �..,� �vu-� - <br /> � City of Orono ��� � � � �� FOR CI USE ONLY <br /> ¢ '� P.O.Box 66 ) � /��Q�' <br /> �`"r � 2750 Kelley Parkway ���_ l Date Receive'df!/� �c� Permit �� �J/i <br /> � �t`��. �• Crystal Bay, MN 55323 �— <br /> ���i��o` (952)249-4600 Amount: $ ��'�J� �� <br /> agxo� <br /> CITY OF ORONO - SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> �ob 5�te r���vner;lr�ifar�a ���'� ` � °�� � <br /> _ .� . ,. <br /> , ' <br /> Site Address: `����� 2� ' � �: '� ���� /�_ <br /> , <br /> �%-��/�;�:y` Mailin Address: <br /> Owner: ,�'� �'���s 9 <br /> City: ���^�� ;;� Zip: <br /> i <br /> Home Phone: (.>�z �7�C �L/��r Alternate Phone: <br /> �`���tr r�� ���r { �r�n��. � �. ��� <br /> �. <br /> Contractor/App.: ��/���i��-r-`�� ;��-�- Contact Person: ��-�y ������,�,�t� <br /> Address: ��;��� �'�- �1 �� State License #: �� <br /> City: �/�� lf ��r Zip: �;5 3s y Expiration Date: -z- /3 <br /> Phone: ��/Z 5/�1 � 7 �-� Alternate Phone: <br /> �x �� �,�, � �:,�";�� ...s ��::', � �� nrT1F�E'S��QF�����.UPANCY ��u' �F�� �� �' '�' �`�'�������' ��:���°������., <br /> � Residential ❑ Commercial ❑ Other <br /> ��� �PERIVIIT-��'YR�E AND FEES � <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ c���, �� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />