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J. <br /> 04p�G City of Orono OR TY USE©NLY <br /> P.O.Box 66 �` <br /> 2750 Kelley Parkway Date Receiu >i, ' Permit = . <br /> Crystal Bay,MN 55323 _ <br /> (952)249-4600 Amount.:e $ � <br /> LIL <br /> VF <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 /> Site Address: 9 is "7-'r <br /> Owner: Mailing Address: 9ist,�,«ia. A$ <br /> City: U (O nv- Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/App.: Contact Person: si t�� 64 <br /> Address: _3 Y7c, State License #: 1 PPY <br /> City: rT«��� Zip: Expiration Date: <br /> Phone: C FS - �3o 3 Alternate Phone: <br /> QN Residential ❑ Commercial ❑ Other <br /> v� <br /> New or Replacement System $200.00 0� <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> CX <br /> Total $ 2 O is- ' <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />