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41.044 y FOR CITY USE'ONLY <br /> P.O.CitBoxof 66 Orono <br /> 2750 Kelley Parkway Date Received: Permit# <br /> V.* <br /> Crystal Bay, MN 55323 <br /> o (952)249-4600 Amount: $ <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 /> n r•I;nformaflonv <br /> Site Address:,?" tc)a..e_ &A, <br /> Owner: g v s yy/ons 5 4/51 iD i1 Mailing Address: <br /> City: X6 � o-� � Gly 6,5-, ,5-6 Zip: <br /> Home Phone: Alternate Phone: <br /> Cat A ` tca t Information: <br /> Contractor/App.:2. �arJ Contact Person: � h �r f <br /> Add ress: / '73 /A rte,'r 5_ I( State License #: o <br /> City: Fv F/9- <br /> 4.1 o Zip: ✓ 3-6' 7/3 Expiration Date: /2) 41. 1e, 'o/ <br /> / <br /> Phone: 74 .3 - `12Y"- i ' �� Alternate Phone: ( �� , p o - / A-/3? <br /> Residential n Commercial n Other <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge .50 .50 <br /> Total $ /0 0.677 <br /> V:\(Permits)\Septic Permit Application-New Permit Fees 2009.doc <br /> 1 / 2 <br />