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4� City of Orono fib FOR CITY USE ONLY efiliC <br /> ' P.O.Box 66 1/24 Q <br /> 't, 2750 Kelley Parkway <br /> /l/ <br /> v" Date Received: O Permit#0 ` <br /> 4 � Crystal Bay,MN 55323 // j <br /> \� Fro• (952)249-4600 Amount: $ L <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: /0 (A) '�,L0 „OR, A, <br /> Owner: 7 kap Mailing Address: (JAI,, <br /> City: ( )20,0 J Zip: <br /> Home Phone: `k 5 a - i+-73 - Alternate Phone: <br /> Contractor/App.: da-(ate. Contact Person: <br /> Address: gC gg 00 109 '44' State License #: q <br /> City: ga(-ee,S Zip: ,S5-3 741 Expiration Date: ©S <br /> Phone: -7G3 - - -7 3 q 3 Alternate Phone: c 01- (o E- <br /> Residential ❑ Commercial ❑ Other <br /> New or Replacement System $100.00 `61 6-‘) <br /> Repair Existing System 50.00 <br /> (Tanks or Drainfield) <br /> State Surcharge .50 .50 <br /> Total $ ti/ 1d. S' <br /> V:\(Permits)\Septic System Permit Application.doc <br /> 1 / 2 <br />