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** ATTENTION APPLICANT *'" <br /> Fiil in ail ap rp opriate blanks and check all appropriate boxes. _ <br /> I will be installing the following: <br /> Tanks <br /> ❑■ Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> ,� Lv C /t/�.EGI 'I""U,p(�c.N�C� o!- 1/�-cs�J��T <br /> Number of Tanks: 2 t�'''�Un w�-� �'�wlc5 - �F �ror ���� <br /> ✓-�GLC l z I�t UtZ C l Uv� s�a-GlLyv �u S <br /> size of Tanks: 1000 1500 <br /> Treatment System <br /> Trenches s.f. <br /> X Mound 45x105 s.f. <br /> Gravel less s.f. <br /> Chamber s.f. <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection. <br /> The undersigned hereby applies to the City of Orono for issuance of a septic system <br /> installation permit, agrees to do all the work in strict accordance with ordinances of the City <br /> and regulations of the State of Minnesota and certifies that all statements made on this <br /> application are complete, ue and correct. <br /> Signature of Applic Date: 9�7/� � <br /> MPCA License No.: � 888 <br /> Staff Review: �„Accept ❑ Denied <br /> Reviewer: �, � Date: �� ����� <br /> o��� v <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> Reset Form <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 � 2 <br />