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ATTENTION APPLICANT'" <br /> Fill in all appropriate blanks and check all appropriate boxes. <br /> I will be installing the following: <br /> Tanks <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> gist rrmufactur+er) <br /> Number of Tanks: <br /> Size of Tanks: L� <br /> Treatment 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 /> i <br /> Date: <br /> Signature of Applicant , <br /> MPCA License No.: <br /> Staff Review: hCAcce pt ❑ Den led <br /> Reviewer. Date_ <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> Reset Form <br /> W.VPermb)1Sepdc Permit Application-Updated Surcharge 7-1-10.doc <br /> 212 <br /> £'d Ll,ZL-ZL6-£9L '00 u0sae1ed •rjewe d00:ZL 06 60 AON <br />