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ATT" NTION APPLICANT <br /> Fill in all appropriate blanks°and check all.lappr"opriateboxes " <br /> I will be installing the following: <br /> Tan <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: 3 <br /> Size of Tanks: 7o 00 /00 0 <br /> Treatment System <br /> Trenches s.f. <br /> Mound 4//0 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 /> Signature of Applicant N . Date: Cp --- 7 <br /> MPCA License No.: �{o <br /> Staff Review: , !d Accept ❑ Denied <br /> Reviewer: /lY ADate: 6 " <br /> c,) 0 <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 />