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(IJpdated 6/2/03) <br /> CIT�Y OF:�RONO APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay,MN 55323 <br /> GENERAL INFOR�TION <br /> 1. You may apply for urility pernrits by mail or in person at the City offices. <br /> 2. Mailed in applicarions are subject to the postage and handling fee shown below. Pemut cards will be sent by return mail the same day ;;� <br /> the applicarion is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. Work must not begin unless the permit card is available on the job site. '� <br /> 5. Utility connecrion pernuts may be issued to licensed contractors only. <br /> 6. Contact the Public Warks Department(952-249-4600)for utility stub as-built locarions. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP ANY MAIN without express approval of the Public Works Department. Issuance of a pernut does not grant this approval. ' <br /> 7. All work must be done in accordance with State Code requirements. �'s' <br /> 8. All work must be inspected before it is covered. Call(952)249-4600,24 hour notice required. <br /> JOB SITE ADDRESS: � � G' ��u �� �C <br /> Occupancy Type• Residential Commercial <br /> Owner's Namec �'- Phone Number• ��Z y7� Z Z�--) <br /> Mailing Address: ' City: �G cI� ` Zip: �?r) <br /> Contractor's Name: Phone Number: <br /> Mailing Address: City: Zip: <br /> PERMIT TYPE ❑Connections ❑Repairs ❑Disconnect (Check One) <br /> `._, <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 sewer connection will not be issued) <br /> Municipal Sewer Connection/Disconnect/Repair ($35.00 per stub) $ <br /> pipe size inches; material Schd 40 air tested; cast iron <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 Ha1L <br /> Water meters must be set and sealed by Orono Water Department <br /> (952-249-4600) upon completion of ineter installation. <br /> REQUIRED 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 Surcharae $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per pemut must be <br /> included for each well,sewer and water connecrion permit requested. � <br /> 3. Posta�e & Handlin� (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT 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 e c mple , e d correcX. <br /> ;' �; <br /> Signature of Applican�• - Date: ��✓�"/�J <br /> �"'' G�C ��� <br />