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Cit of Orono FOR CITY USE ONLY <br /> ie 0'• PO.Box 66 <br /> i 0 2750 Kelley Parkway Date Received: Permit# L )-©I 377 <br /> Crystal Bay,MN 55323 _,�,,1 <br /> ki!tAk,''04# (952)249-4600 Amount: $ pj�S CZ) <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 /> 7.11-La�§ �^v��' his`,. <br /> 4 kid i�.;�". <br /> LIZ CW,4 I �"v f lJ i� <br /> Site Address: �) �J (((� l� <br /> Owner: v\ �h�� Mailing Address: 5rstit <br /> City: L; •\/c..7 -\-c Zip: <br /> Home Phone: Alternate Phone: '( et �- ¶ Zz <br /> V►-�, }� c1 (4 C k,z.( hcr�c <br /> '1'11112;E: .111:1 ,. <br /> Contractor/App.: 14 A le-5> +-c>.4- '\ s Contact Person: ( 5I-'f Q <br /> Z63 r 5- SL <br /> Address: ` State License #: <br /> City: 07.. 54' Zip: 53(47 3 Expiration Date: <br /> Phone: 74, 3,- 7�--- ( 7 2- Alternate Phone: 4 /1- to �7 S <br /> Residential ❑ Commercial ❑ Other <br /> IS`s g 1 ' k rr,:+as... <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ 2 0 <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />