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J�, FOR CITY USE ONLY <br /> ' ,¢p� City of Orono <br /> P.O. Box 66 p-7 <br /> �� � 2750 Kelley Parkway Date Received: Permit � aZ-" D / <br /> a� '�� {�. � Crystal Bay, MN 55323 Amount: � C' �_�.�� <br /> d��'�,,,�'�y�:.$o (952)249-4600 <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 SE�'�/'�,uur�er Information: ��.� ,�,�:��; <br /> _ , <br /> Site Address: � ��� � � X � (`� ��r�Q lU' <br /> Owner: L +q���%' D,� --�-e-!'r�ti' Mailing Address: S� � � <br /> City: L- U!l 5 C, �) i�C� Zip: �S � ��a <br /> Home Phone: Alternate Phone: <br /> ���tractor:/,Applicant lnforma��� 'fi� �5:, <br /> �. �� �. <br /> Contractor/App.: � f) �-t e,� � �}� S Contact Person: ��� � <br /> i� � / c� <br /> Address: 7� � i�'/�� ����' State License #: � `p l � <br /> City: %�"��12�7"�SG Zip: ��3`��� Expiration Date: �� " d G� � Z-- <br /> Phone: 7�l �% � � �— ��,/� Alternate Phone: �/Z b �5'� �S S� <br /> � ` � r �gF�� <br /> � ;:�����,' �����`��� ' "T�P��S°`�����GUP��AN CY ��� :�������' ,����.��` � <br /> �Residential ❑ Commercial ❑ Other <br /> � ���, €. ,` ���� PERMIT TYPE�AND FEE� ��r,., ,�,,,�� , i <br /> New or Replacement System $200.00 2 C�C'�-��: <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ �b ��C�� <br /> W:\(Perrnits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />