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. �` � � ¢�� City of Orono FO CITY USE ONLY <br /> O.� O P.O. Box 66 /� D <br /> fl 2750 Keliey Parkway Date Received: ��� Permit# �lQ' �' <br /> �7�r <br /> ��� ��- � Crystal Bay, MN 55323 ��-7� <br /> ,�,�yo (952)249-4600 Amount: $ Q .v�/ <br /> CITY OF ORONO — SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> Job Site� ""�er Informatia ;� ,'°�� ' '`` <br /> �� <br /> Site Address: 1���t� 5� I,;�- - Sh�.�l���� D�, Jr <br /> Owner: � Mailing Address: S i�m� <br /> City: c�Y�;� Zip: <br /> Home Phone: rJ� Alternate Phone: ��z zz i -i�1��Z <br /> ��Contractor/Applicant InformationM��''^ ��y,p'���r�"��'�', <br /> Contractor/App.: ��,Y�.1�, -3;.�+�,,.,5 �, Contact Person: �i�� <br /> Address: P-�� - �� 55 State License #: Z'7Z��7 <br /> City: ���1..� mJ Zip: Ss 3�� Expiration Date: /- zb- i / <br /> Phone: c��Z Z��I -I-��t� AlternatePhone: ���z zz�-i4��3 <br /> �,�:: ��,A� �� ��� ��� ,,��� . ,�, ��"�"�'PES OF OCCUPANCY � ,t ---� <br /> �Residential ❑ Commercial ❑ Other <br /> ����� ,�,�� ��y� �_ , ����,: PERMIT;TYPE AN°���EE� �''� "' y� �"", , .,�;� � �.� <br /> ,�,.� .�� �.� <br /> New or Replacement System $200.00 Z�:� ���, <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total � Z c,�_ � <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />