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** ATTENTI <br /> Fill in all appropriate blanks and check all appropriate bo <br /> I will be installing the following: <br /> Tanks <br /> recast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: <br /> Size of Tanks: 4DZ90 <br /> Treatment System <br /> Trenches S.f. <br /> Mound S.f. <br /> Gravel less S.f. <br /> Chamber s.f. <br /> Final Cover/ Top Soil <br /> to be borrowed from site (show location on site plan) <br /> trucked in <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 /> 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 /> V:\(Permits)\Septic Permit Application-New Permit Fees 2009.doc <br /> 2 / 2 <br />