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Cit of Orono FOR CITY USE ONLY <br /> P.O.Box 66 <br /> 2750 � <br /> City <br /> Date Received: 7-3-/ 1 Permit# � ,//1`'d� fir <br /> Crystal Bay,MN 55323 <br /> (952)249-4600 Amount: $ <br /> y Q�1 Kelley Parkway l <br /> F �, <br /> lgkfSt{p � <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 /> Job Site/ Owner Information: <br /> Site Address: Z 3LvC.) ( /0I Lf <br /> Owner: .SI-44/-1 a Ai/fripl,LjL-5 V i Mailing Address: Z'-(& ) 77-16va bIi/2/_4:/ L/ll <br /> City: Zip: 32.5.3.54c <br /> Home Phone: Alternate Phone: <br /> m" s a5 �-,�. r <br /> Contractor/App.: /731,zgir/3 L--r/'iJvii/dt7it / ,-ite` Contact Person: 3 evc I L.L/Zrt�a <br /> Address: ,'&4176 CG i, by /16.1( 2' / State License #: / $ <br /> City: /A1`4\/L/2 Zip: .S 3&/) Expiration Date: /Zl/1di5 <br /> Phone: ( 15Z) qT -'r t? Alternate Phone: (ll./Z) 6'6'5'L/36,5. <br /> PES OF OCCUPANCY <br /> EXI Residential n Commercial n Other <br /> PERMIT TYPE AND FEES: ' ' ' ,V P5 <br /> New or Replacement System $200.00 ZOO <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ 14 Z/Y5 <br /> W:\(Applications,License or Permit Applications)\Permits\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />