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r <br /> O City of Orono FOR CIJ�USE ONLY <br /> , � �� 2760K elley Parkway � Date Received:�� �, � S1�3 Permit# ai3-�i <br /> Crystal Bay,MN 55323 �� D'C/ <br /> (952)249-4600 ����� ,' 1- Amount: $ ��� <br /> � � ..� <br /> y '� '1 <br /> F �. <br /> `�K£S H��� �� <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 / Owner information: <br /> � � <br /> Site Address: -� �� � �� � b S (.� �` " — � •� <br /> Owner: ��v�,� ��'�-r �''� L( Mailing Address: 5���(� <br /> � <br /> City: y��= �� Zip: <br /> Home Phon�: Alternate Phone: <br /> Cantractor/Applicant Information: <br /> Contractor/A � ��r%� Contact Person: R-�� <br /> pp�� ` <br /> Address: <br /> �-b3 �Z'���� State License #: Z— � �� <br /> City: �'�l1Lt�Z�i�� Zip: Expiration Date: ��'� � �� <br /> Phone: �)(�,�'" ��� -- � _/ ��--- Alternate Phone: �����—�����-�1 <br /> 7�3 -�I-'1 g - 1'7�c �. <br /> TYPES OF OCCUPANCY <br /> Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES <br /> New or Replacement System $200.00 ��� � <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ �U S �"� <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />