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FOR CI USE ONLY <br /> 0 City of Orono <br /> 1 0 �� PO.Bax 66 <br /> /S/1--9/1 /7/ Permit#01011-060434" <br /> �r,L 2750 Kelley Parkway Date Received: <br /> �`a - Crystal Bay,MN 55323 Amount: $ C.0�s• 47) <br /> (952)249-4600 <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: ! 25 bU I oc,,_) Dt2, - <br /> Owner: i3 t < < ,i-Dem�Se LQ..S t Mailing Address: <br /> City: CJ Zip: 5-.5-3 2-3 <br /> Home Phone: `i Z — 21,Z Alternate Phone: <br /> 1:7,-1/:!'"7.1T <br /> Contractor/App.: )G,u' k,.) Contact Person: <br /> Address: 2- 3 2 f 5 State License #: L C C, 5 V <br /> City: 71'70.31ros--e Zip: Expiration Date: / b (1 / - 3/ /Z <br /> Phone: -7 b/?"1179 Alternate Phone: ko(Z- 6�'�` 755-0 <br /> ::--,c `,..-111117,217 <br /> c ` 1N ��'7E p s D � _ �.�` '�+��' T <br /> Residential ❑ Commercial ❑ Other <br /> 777377;?:;"f ,°€ d ) ii F.:71077:: <br /> . <br /> �V <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ <br /> Z "`- <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />