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City of Orono FOR CITY USE ONLY
<br /> 4-4/1.0:4po
<br /> \\ POBox662750 Kelley Parkway Date Received: 7P-2-110 Permit# .fr/O "(I, 6'/L
<br /> Crystal Bay MN 55323
<br /> i 0, 4 (952)249-4600 Amount: $ U1a5.619
<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 /> Site Address: 9 zoo W ze-L` . I VC
<br /> Owner: 01 }Ce l .Vil'C9GG Mailing Address: 920 td-47-,k.4c ( ( J,
<br /> City: 0 VCy Q Zip:
<br /> Home Phone: r(Z- V76 --d 731 Alternate Phone: 4/Z - 64;i - 73 60
<br /> a 0 it/Applicant Information:
<br /> Contractor/App.: I p‹.7 4--Swr �
<br /> �S Contact Person: P
<br /> Address: 24 3 2`— $4- . S State License #: YcCr LK
<br /> City: f/hJ'l-`ifruS-e Zip: S- ----3(o 3 Expiration Date: ?6/ Z--
<br /> Phone: -2e.e. ?-- (4--7 S - (96 r2— Alternate Phone: ('p (2_ - 6 3-5-_` oi5Z)
<br /> � x * ,`�F# „,-,,„, °wet"'xv 'v»�r ,c x ., �§,.�, 3 T iw3
<br /> . .. ,� ,..s. ., 9s....v .,..,._ ,.,.,.ate ,
<br /> ,esidential ❑ Commercial ❑ Other
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<br /> ` t :. ." ,:g.:`t, ,., '� w °d' fes' '"�"i �'" s= : ,, i® ` €. �$ s1,* ^w+'�,4'T,,: ',� 17'x:" e'
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<br /> New or Replacement System $200.00 ©0
<br /> Repair Existing System 100.00
<br /> (Tanks or Drainfield)
<br /> State Surcharge 5.00 5.00
<br /> Total $ 2_c, --c, g .=-
<br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc
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