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• 3 <br /> SKETCH: Submit licensed site evaluation, design, sketch and management plan with <br /> application. If substantial changes are made to the design during installation, a new design <br /> must be submitted with the date and designer's signature prior to installation and inspection. <br /> Completed Site Evaluation ,A�Yes ❑No Date I,, �ra���' <br /> i � <br /> Completed Design Worksheets ❑Yes ❑No N.4 Date <br /> Compliance Inspection ❑Yes ❑Noi✓✓� Date <br /> Management/Monitor Plan �`.;'t]Yes ❑No Date Approved <br /> �,� � �-• t � 1✓�� S ; ,���E' <br /> AGREEMENT: I/We the undersigned, hereby make application for work described and located <br /> as shown herein. I/We certify that the information contained herein is correct and agree to do <br /> the work in accordance with the provisions of the Orono City Code and the State of Minnesota <br /> MPCA Rules 7080-7084. I/We further agree that any plans, specifications, or drawings <br /> submitted rewit a e accurate and shall become part of the application. <br /> _ ///3--�c� <br /> Sig ture of Ho' eowner or Agent Date <br /> PERMIT: Permission is hereby granted to the above named applicant(s) to perform the work <br /> described in the above application. Any and all changes to the approved design shall be <br /> reported to the designer and to the permitting agency prior to the completion of the work. This <br /> permit is granted upon the express condition that the person to whom it is granted, and his/her <br /> agent, employees and workers shall conform in all respects to the Orono City Code and the <br /> State of Minnesota 7080— 7084 Rules. This permit may be revoked at any time upon violation <br /> of said ordinances and codes. This permit expires on December 31 of the year in which it is <br /> issued. This permit, with all supporting documents, will become a permanent part of the <br /> property records on file at the Orono City Hall. <br /> A! <br /> Communit Developme irector or Designee ate <br /> Return this Application to: <br /> Physical Address: Mailinq Address: <br /> City of Orono City of Orono <br /> 2750 Kelley Parkway P O Box 66 <br /> Orono, MN 55356 Crystal Bay, MN 55323 <br /> Phone :952-249-4600 ..,.., ��� �;�._,;�_, � ��� � : <br /> _ _ __ _ <br /> Fax: 952-249-4616 :n;.,�k�ii!r,i ��r��r��i.ni��� �;�, <br /> Septic Permit—Revised 7/8/2014 Page 2 of 3 <br />