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07/19/2013 08:58 952-955-5071 BURNS EXCAVATING PAGE 02 <br /> Clty of Orono <br /> , 74;7 <br /> USE ONLY <br /> Po.O.Box 68 � <br /> 2750 Kelley Parkway Datef�eteivePermit#2DS, v�.7 <br /> Crystal Bay,MN 55323 <br /> (952)249-4600 Amount: $ .00 3 -U �� <br /> F , <br /> 1�krsHc)�� <br /> CITY OF ORONO—SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Sete Septic Manager and/or Building Official) <br /> Site Address: Z 5 ZS L )J LL/,/.0 /j ZL 1\ 16 <br /> Owner: (rtJI 14 Mailing Address: mrS 1/(, V,1W &2 <br /> City: Zip: ,"55357 <br /> Home Phone: Alternate Phone: <br /> I�144.: n i n i nj 1 I r ! Mai., iy i <br /> '1� / �+14.�. .Afn �' <br /> Contractor/App.: &l, RAJ Oizei11/IT1i, Contact Person: "t/ s <br /> Address: 3,1176 ezAd l,-y ,14"J zL State License #: / 8&8 <br /> City: t4 L 1Z Zip: 5:53/J0 Expiration Date: Z/?6/4 <br /> Phone: /464 9 Alternate Phone: /'c/z) bits— 4/36,. <br /> e }II���r � ..� .' k.t�^�:�����r,�Stu'..'!�!i�I✓z f, � _� ..... (t.; r.�'dklY�11��'kJiy �S�Ny� ,�p� h;� ...yx�,l'xi�d„71a d,� <br /> ,�.,& �4 2. M,Gui(e,L?L.�..dr.\..l.G�,..:1i.�'.a...�yL• , � ,:,.a, f. S <br /> LFII Residential ❑ Commercial ❑ Other <br /> �'�+lµ:`;Ai” nr�:� i;, F,. j�tG ith� �.t; II � _;.� _ + ��,� ,fir <br /> W . �; ?a.; .w",r' ki4 '�:�r+[',., ;y4 �1:In jZI.11.,.1,d+!4�Li 17 i �A,.,1'�1+4'' ,k,ar,'1 L ,M*.0.. <br /> r <br /> s r Replacement System $200.00ZOO ' - <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ Z 6 S 41') <br /> W:1(Applications,License or Permit Applicatiens)\Permits\Septle Permr..Appllcation-Updated Surcharge 07-28-1I.doc <br /> 1 / 2 <br />