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Cit of Orono lam' FOR CITY USE ONLY <br /> r <br /> PO Box66I0 3 Date Received: 'iii Permit#& t- s�2750 Kelley Parkway <br /> ' ,, Crystal Bay,MN 55323 <br /> '' ; 4tI' (952)249-4600 Amount $ /Pd <br /> fro$ <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: Lf (0 f v`-'-`-‘4-- ('`---C' <br /> C(A✓N\Qv� CU3 Le IAA �{ <br /> Owner: .�� � rove Mailing Address: (/ 6 5- w. 13,,,, k K--I- <br /> City: ()vo--,,\_,,,:::. Zip: <br /> Home Phone: Alternate Phone: <br /> Q cls c .._gsw . <br /> Contractor/App.: (n y &3 + S,,---h S Contact Person: 2 A <br /> LE <br /> Address: 2 G 3 t 5 f_ 5 e- , State License #: `' <br /> City: // `f'o�e Zip: C--(----3(,..3 Expiration Date: Pec • v <br /> Phone: 7 ? f 7 f- (762— Alternate Phone: 1.,(2- 6 F5- —9 SSU <br /> ,,,.„ :....`7 ,<..._sr.''..�,<.._, _......,....ren .. -:,„,„„„,s LuhYw !c. ) ` > r. F[ f, ' fei 7:'a”sl :t k', _+ 4 <br /> ,ii(Residential El Commercial ❑ Other <br /> New or Replacement System $100.00 /0() v- <br /> Repair Existing System 50.00 <br /> (Tanks or Drainfield) <br /> State Surcharge .50 .50 <br /> Total $ j000,5-0 <br /> V:\(Permits)\Septic System Permit Application.doc <br /> 1 /2 <br />