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(LTpdated 5/3/02) <br /> CI'I`Y:OF i�►�20N0 APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay, MN 55323 <br /> GENERAL INFORMATION <br /> 1. You may apply for utility pernuts by mail or in person at the City offices. <br /> 2. Mailed in applications 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 begin unless the pernut card is available on the job site. <br /> �. Utility connection permits 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 Department. Issuance of a pemut 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 /> JOB SITE ADDRESS: �� � a� Y1 c�� �C� O r �tih�Cy <br /> Occupancy Type: L� Residential Commercial <br /> Owner's Name: �e����'�.��S Phone Number: � � � �'�� ��'�'� <br /> Mailing Address: City: Zip: <br /> Contractor's Name: � 'U .� �'�-�'� Phone Number: S�-•c-f 7-i �-3 ( � <br /> Mailing Address:s�$�.S�.,�c�e V-�cZ-- City: rn o���. � Zip: � '1.�� <br /> PERMIT TYPE�'�nnections ❑Repairs ❑Disconnect (Check One) <br />�:K <br />�����`: SAC Charge (2002 rate $1,200.00) $ (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 onnection/Disconnect/Re�ir($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 Hall. <br /> R'ater meters must be set and sealed by Orono Water Department <br /> (9�2-249-4600) 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 Surchar�e $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per permit must be <br /> included for each well,sewer and water connection pemut requested. <br /> 3. Postage & Handling (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 ar complete, tru d correct. <br /> Si�ature of Applican : ' Date: � � � O � C � <br /> d� P <br /> �/ (_ CZ ssesSa�� � �.5 5`� � <br /> � .� `��,�� Co r��f;�•f�f� �e e- ��� �- \ ��I i.`' <br /> ` - nL r l.kq��� (�{�Otl O ) <br />