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** ATTENTION APPLICANT ** <br /> Fill in all a ro riate blanks and check all a ro riate boxes. <br /> I will be installing the following: <br /> Tanks <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> Qist manufacturer) <br /> Number of Tanks: .-? <br /> Size of Tanks: �r���'G' ���Gc�, ��'c`%�� <br /> Treatment System <br /> Trenches s.f. <br /> � Mound ' 3 �C�> 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 correct. <br /> :�--� , �, <br /> � <br /> Signature of Applicant `���''�% Date: �' � y����J <br /> T.�%' <br /> � <br /> MPCA License No.: � �� <br /> Staff Review: �-Accept ❑ Denied <br /> � <br /> � '� �. <br /> � <br /> Reviewer: /�,�%� L-t, � -'� Date: ��- � - � �� <br /> a <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> V:\(Permits)\Septic Permit Application-New Permit Fees 2009.doc <br /> 2 / 2 <br />