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(iJpdated 6/2/03) <br /> CI�i Y G� ORONO APPLICATION FOR UTILITY PERMITS � <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay, NIN 55323 <br /> GENERAL INFORl�IATION <br /> 1. You may apply for urility permits by mail or in person at the City offices. <br /> 2. Mailed in applicarions are subject to the postage and handling fee shown below. Permit cards will be sent by return mail the same day <br /> the application is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. Work must not be;in unless the permit card is available on the job site. <br /> 5. Utility connection permits may be issued to licensed conh-actors only. <br /> 6. Contact the Public Works Department(952-249-4600)for utility stub as-built locarions. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP A�1Y MAIN without express approval of the Public Works Department. Issuance of a permit does not grant this approvaL = <br /> 7. All work must be done in accordance with State Code requirements. <br /> 8. All work must be inspected before it is covered. Call(952)249-4600,24 hour notice required. <br /> �, �� <br /> JOB SITE ADDRESS: Z �' t� ___ (/�� 1 <br /> Occupancy Type: Residential Commercial <br /> Owner's Name: /t/ /-�- Phone Number: <br /> Mailing Address: �. A._ City: Zip: <br /> Contractor's Name: �/ f`„�-}���i(i,r 5 c� � I'�'',cJ�,..� Phone Number: �/s2_ Y�3- 3 57� <br /> Mailing Address: .�p City: (•✓.4c z�: Zip: � s���/ <br /> PERI�IIT TYPE Connections ❑Repairs ❑Disconnect (Check One) <br /> SAC Charge (2003 rate $1,275.00) $ (Set Rate) <br /> Sac Charge must accompany all sewer permit applications unless prepaid. <br /> (If not prepaid, a se���er connection will not be issued) <br /> Municipal Sewer nnection/Disconnect/Repair ($35.00 per stub) $_ .. <br /> �`�a�� <br /> pipe size�inches; material chd 40 air tested; cast iron <br /> -- 5/.�1�I/_ <br /> Municipal Water Connection/Disconnect/Repair ($35.00 per stub) $ <br /> pipe size inches; material copper; other <br /> WATER METERS must be picked up and paid for at City Hall. <br /> Water meters must be set and sealed by Orono Water Department <br /> (952-249-4600) upon completion of ineter installation. <br /> REQLJIRED minimum setbacks from drain field and septic tanks = 75' <br /> REQUIRED setback from sewer line=20' <br /> PERMIT FEE CALCULATION <br /> 1. Subtotal of above permit requested $ <br /> 2. State Surchar�e $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per permit must be <br /> included for each���ell,sewer and water connection pernut requested. � <br /> 3. Posta�e & Handlin; (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PER�iIT FEE (add lines 1-3 above) $ <br /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do all work in strict <br /> accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements <br /> made on this application ar true and correct. <br /> Signature of Ap nt: Date: /��� <br />