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* tE W 104 APPL Ax <br /> Fill in all appropriate4414pIcs` d cheek°all'appropriate` oxes. _.. <br /> will be installing the following: <br /> Tanks ` Fi <br /> .Vi *: : r <br /> �] Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> y (list manufacturer) <br /> Nt�rxrtar of an s: 1 <br /> a <br /> _T'reaiment`System <br /> Trenches s.f. <br /> Mound 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 /> Signature of Applicant Date: <br /> MPCA License No.: <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 />