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�, <br /> CITY OF ORONn A- ApPLICATION FOR UTILITY PERMITS <br /> �,�-. <br /> �`� Box 66 (1335 Brown Road So) �EWER WATER W�LL <br /> �"' Crystal Bay, MN 55323 <br /> ************************************************************************** -� <br /> General Znstructions `:� <br /> 1. You may apply foz utility permits by mail or in person at the City offices. <br /> 2. Mailedin applicationsare subject to the postage and handlingfees shown below. Permit cazds will <br /> be sent by return mail the same day the application is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. work must not begin unless the permit card is available on the job site. <br /> 5. Utility connection permits may be issued to licensed contractors only. <br /> - 6. Contact the City offices for utility stub as-built locations. DO NOT EXCAVATE ZN RNY STREET AND DO <br /> NOT TAP ANY MAIN without express approval of the Public Works Department. Issuance of a permit <br /> si� does not grant this approval. <br /> �.,�, 7. All vork must be done in accordance with State Code requirements. <br /> ��-: 8. All work must be inspected before it is covered. Call 4J3-7357. <br /> s��e,a_�� � � <br /> �; *�Ir**�r***it*�Y�rxsk*ik�riric�kic�ticstiyk4c�tytik�k �t*a�ryk��t�t****��i�ir*�r**�r**ir**�c*�t*�l�c�:*�tir�t*4c�:s�ic�:� <br /> # � � f� <br />�&:. : JOB SITE ADDRESS ,_�L�C%� ;�--'J`�--� lL'�.,, �� �`�,l�,!t"z--�_G�.�.c� � - <br /> Occupancy �ype: X Residen�i ' Commercial <br /> �1M6��, �lr <br /> �� OWNER`S NAM�; ..�s�f;C::i.�t.J (.:�C!)Z�, l.�l�, � ::Tele anc� Np: G <br /> ' � '�"�Mailin Addres� � �� �� � ""� <br /> g �- S � ,� � ", �-�•.-� : Gt��C. � �° <br /> S ' . :��.. . . .�.... � - . � . .. ,�-m+�.a�.��� <br /> ��:'` CONTRACTOR e S I�T L',..,ti�vX� �rru_f � (� , B s i n�� Na. %�� � %�,� <br />µ�x° M a i l i n g A d d r e s s � i a ��_ <br />�; Master�� Plumb�r` s Stat� LYcense I�o� � �(� �� Gity Cer�.. Na. �� � <br /> �''; ******�c****yYsY�k�lc*�cic��lrirsc*�k�k�ti�4c�t�r�k�r�r4ca4*�c**�cyY�c*�ti;�kix*�F*�Y*�t*�t*�tic#ic�r#�k�Y*�:ic*��tic�k�stsM <br />����' � � ���ZMIT T�,'�E AND �`�� CALCIJL7�TIf�� � � ��; <br />„�,_ ,� <br /> N.. �.. . � � _ . . . <br /> ��. MIINICIPAL SEWER GONt�IECTION ($3 0 per stub} $ � U - �'` � <br /> pipe size inches; ma�erial PVC (on sand fill) ; ° <br /> �� cast _iron <br /> . SAC Charge ($425 . 00 ) must accompany all sewer permit applica�i.ans u�SJ_ess <br /> � prepaid. If not �repaid, a sewer connection permi� will not be issued. ' <br /> :,:'. <br /> MUNICIPAL WATE�t Cdk'N�C��01N ( $3 0 per stub) $ ,,�G� , C%C� . <br />� pipe size �.nch�s; ma�eria�. _ c��.��e�r <br /> other � �^ <br /> WATER METERS must be picked up and paid for at City Hall. <br /> (5/8" meters = $95� OQ 3/4" meters = $130. 00 } <br /> � PRIVATE WELL INSTALL�.TIQNS ($30 per job) $ <br /> 3.;; check: - new well replacement well <br />�'"` repair existing well <br /> ��,,;,; casing size: inches <br /> e '� REQUIRED minimum setbacks from drainfield & septic tanks = 75 ' <br /> CALL FOR A SITE LOCATZON BEFORE DRZLLING <br /> _ - Upon completion, City must be sent a copy of state well record. <br /> *******************�**********************��*�**************************�* <br /> µ- '1. Subtotal of above permit requested $ (� fU, Ce C> <br />�� 2. State Surcharge $ �50 <br /> ' The State Buildin Code Division Surchar e of $.50 p <br />, �. 9 g per ermit must be included for <br />��:�: each well, sewer and water connection permit requested. � <br />�� � <br />�; 3 . Postage and Handling (Only mail-in applications) $ .�- . <br />��'' 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ � C�, s U <br /> ******************�*********��***�******************************�*�a******* <br /> � ;:' The undersigned hereby applies to the City of Orona for issuance of a UTILITX <br />�.; PERMIT, agrees to do all work in strict accordance with the ordinances of the City <br />` " and the regulations of the State of Minnesota, and certifies that all statemen'ts <br /> made on this application are complete, t ue and correct: <br />' � � G'� � C� '�? <br />�� Signature of Applicarrt t�,c�� �� CC� Date: x ` l� " � <br />