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(Updated 1/5/04) <br /> CITY O�ORONO APPLICATION FOR UTILITY PERMITS <br /> Box.d6 (2750 Kelley Parkway) SEWER/WATER & SAC <br /> Crystal Bay, MN 55323 <br /> GENERAL INFORNIATION <br /> 1. You may apply for utility pennits by mail or in person at the City offices. <br /> 2. Mailed in applications are subject to the postage and handling fee shown below. Pemut cards will be sent by retum mail the same day <br /> the application is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. Wark must not begin unless the peinut card is available on the job site. <br /> 5. Utility comtection pernuts may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department(952-249-4600)for utility stub as-built locations. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP ANY MAIN without express approval of the Public Works Deparhnent. Issuance of a pernut does not grant tl�is approval. <br /> 7. All work must be done in accordance with State Code requirements. <br /> 8. All work nnist be inspected before it is covered. Call(952)249-4600,24 hour notice required. <br /> JOB SITE ADDRESS: /��� �� -����lf ���`'� <br /> Occupancy Type: /� Residential Commerciat <br /> Owner's Name: "�..� �v�l=����- Phone Number: <br /> Mailing Address: _ �,-� �-- City: Zip: <br /> Conh-actor s Name: C ��•c j?c�-y�'-- .��� <br /> r �/,��l.�rr�� �c.,:ij,—���-c,-,,,,� Phone Number• <br /> Mailing Address: 9�%=s— �:rf i�( �s— City:/��,��`-.�i.:�Zip: ��_;5- � <br /> PERMIT TYPE ❑ Coiuiections ❑Repairs Disconnect (Check One) <br /> SAC Charge (2003 rate $1,350.00) $ (Set Rate) <br /> Sac Charge inust accompany all sewer pennit applications unless prepaid. <br /> (If not p►•epaid, a sewer connection will not be issued) <br /> Munieipal Sewer CQnnection/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.3� inches; material�opper; 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 /> REQUIRED minimum setbacks from drain field and septic tanlcs = 75' <br /> REQUIRED setback froin sewer line=20' <br /> PERMIT FEE CALCULATION <br /> 1. Subtotal of above pennit requested $ <br /> 2. State Surchar�e $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per pernut must be <br /> included for each well,sewer and water connection perniit 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 are complete, true and correct. <br /> �_� <br /> C-.. ��� <br /> Signature of Applicant: �rv -�~� Date: _/�S/ <br />