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NOTE: Applicant must initial all spaces. Fill in all appropriate blanks and check all appropriate <br /> boxes. <br /> 1. I have received a copy of the system design including the City of Orono Septic <br /> System Approval Cover Sheet. / /ter <br /> 2. I will be installing the following:2-/-1-0/a( Tet,?- S - k-S � '\1 <br /> A. Tanks: X' Precast Concrete Other Manufacturer Ci 03" <br /> Tank Capacities: 1) /S Lt) gal. 2) %S W gal 3) gal <br /> B. Pump Station (if required) <br /> Pump make& model (attach pump curve& <br /> literature); system design requires gpm at feet of head. <br /> High water alarm make & model . Outside <br /> electrical work to be completed by installer electrician other. <br /> C. Treatment System: <br /> Trenches: s.f. Mound <br /> Depth of rock below pipe " Rock bed dimensions ' x <br /> Drop Boxes Sand bed dimensions ' x <br /> Distribution Box Pressure Dist. Pipe Diam. " <br /> Manifold Pipe Diam._ " <br /> D. Final Cover/Topsoil to be: borrowed from site <br /> (show location on site plan) <br /> trucked in <br /> The undersigned hereby applies to the City of Orono for issuance ofa septic system installation permit, <br /> agrees to do all work in strict accordance with ordinances of the City and the regulations of the State <br /> of Minnesota,and certifies that all statements made on this application are complete,true and correct. <br /> Signature of Applicant / Date: 2 %� 2— 0 <br /> MPCA License No. <br /> • <br /> Staff Review: Approval neDenial <br /> Reviewer: t Date: 2 - ZZ—ca <br /> Reason for Denial: <br />