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r O City of Orono FOR CITY USE ONLY <br /> P.O.Box 66 <br /> 0 2750 Kelley Parkway Date Received: rP'll' Permit# r ►S <br /> Crystal Bay, MN 55323 <br /> (952)249-4600 �a/,n1' �� Amount: $ <br /> y � <br /> lgkESH0�� <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 /> Job Site / Owner Info:` <br /> Site Address: 10,' D[ I <br /> Owner: U :n '--� �t ' J Mailing Address: <br /> City: Q ro Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor I Applicant InformatiollijAWN <br /> Contractor/App.: Contact Person: r` <br /> Address- 'Or-q C'C_ 4 Ue S� State License #: � lf ° <br /> City.. Or_fe,nc- Zip: J 5,� Expiration Date: <br /> Phone: (/ (.YJ. 722-.-2-YA0, Alternate Phone: / 2�2,82--7S0 <br /> , YPE&OF OCCUPANCY, „ <br /> �J Residential ❑ Commercial ❑ Other <br /> New or Replacement System $200.00 200,00 <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ � � S _ou <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />