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4 <br /> NOTE: Applicant must initial all spaces. Fill in all appropriate blanks, check all appropriate <br /> boxes. <br /> 1,,,5 m,a,),c- Air ox 2O0 1/_ 9 It Ate.-1-/, - %i t(s <br /> iv 1. I have received a copy of the system design including the City of Orono <br /> / Septic System Approval Cover Sheet. <br /> i .2. I will be installing the following: <br /> A. Tanks: _ Precast Concrete _ Other Manufacturer <br /> Tank Capacities: 1) /604) gal. 2) /60,-a gal. 3) gal. <br /> r' <br /> r. <br /> B. Pump Station (if required) <br /> I;,-:)(( <br /> i5/:Ai Pump make & model (attach pump curve & <br /> literature); system design requires gpm at feet of head. <br /> kHigh water alarm make & model <br /> ' Outside <br /> electrical work to be completed by installer electrician <br /> \ other . Inside electrical work must be completed by <br /> electrician. <br /> C. Treatment System: <br /> Li Trenches: /Zoo s.f. Mound <br /> Depth of rock below pipe 6," " Rock bed dimensions 'x ' <br /> L.4 Drop Boxes Sand bed dimensions 'x ' <br /> Distribution Box Pressure Dist. Pipe Diam. II <br /> I' Maniford Pipe Diam. II <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 of a septic system installation <br /> permit, agrees to do all work in strict accordance with the ordinances of the City and the <br /> regulations of the State of Minnesota, and certifies that all statements made on this application <br /> are complete, true and correct. <br /> SignatureofApplicant: Date: /6/22/5 <br /> MPCA Certification No.: - 9s <br /> Staff Review: Apprsv. , Denial <br /> .000., <br /> Reviewer: if <br /> iI��e: `�: rW/i Date: .7° <br /> .-- sYg. . <br /> Reason for Denial: <br />