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�J-�7q�, <br /> O City of Oron OF F RCITY USE LY <br /> P.O. Box 66 �IT <br /> 0 2750 Kelley Par ay D Received: �� Pe it# 1 <br /> Crystal Bay, MN 233 <br /> (952)249-4600 ate 1L <br /> V" <br /> el <br /> 4ael <br /> `�kfSH <br /> CITY OF OR NO — S IC SYSTEM P Mb%APPLICATIOU— <br /> (All permits mu t be a r an or u Official) <br /> For Code omphan <br /> Job Site / Owner Informs - r/y/ Q�► <br /> �,�► � woo <br /> 49 <br /> Site Address: Sa O <br /> Owner: b%e7il IJv /L Iq Mailing Addr �SA T�P �ST <br /> City: O Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/Applicant Information: <br /> D <br /> Contractor/App.: Contact Person: <br /> Address: �`� 2 �.� W c �� S/—C State License #: <br /> City.. DC-/CIA o Zip: � Expiration Date: <br /> Phone: ��, � 2 ' 2- 2Alternate Phone: <br /> TYPES OF OCCUPANCiy � ..: <br /> ❑ Residential ❑ Commercial ❑ Other <br /> T{ } <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 $ cpo'5� dD <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />