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. � <br /> ** ATTENTION APPLICANT ** �� '� <br /> , Fill in all appro�riate bianks and check all appropriate boxes. <br /> I will be installing the following: <br /> Tank <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other � �w�'-� <br /> (list manufacturer) <br /> Number of Tanks: � <br /> Size of Tanks: 1 �� !�`�uc� �C1 v <br /> Treatment System <br /> Trenches s.f. <br /> Mound U s.f. <br /> Gravel less s.f. <br /> Chamber s.f. <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection. <br /> The undersigned hereby applies to the City of Orono for issuance of a septic system <br /> installation permit, agrees to do all the work in strict accordance with ordinances of the City <br /> and regulations of the State of Minnesota and certifies that all statements made on this <br /> application are complete, true and corr ct. <br /> ---- <br /> ___--------_ -_ <br /> Signature of Applicant Date: <br /> � S � f ��. <br /> MPCA License No.: � <br /> C�� TC� <br /> Staff Review: �Accept ❑ Denied <br /> Reviewer: /�../ �� � �� Date: �' � — �� <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />