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07/19/2013 08:58 952-955-5071 BURNS EXCAVATING PAGE 03 <br /> 4 <br /> as.1417 �br ta- '4 V � <br /> "Y1,14.4':1".4-LA <br /> t Fa,r r i_G "Y1 rl.M1" `.t. <br /> a 1 y1c�` khw1` .f� a44 >1.^": G44rL :t4'. <br /> I �YL6.L'!7�'� :JiGla�'� '�`•+C .I,-i• •r� ;, �lA�i(M <br /> I will be installing the following; <br /> Ta ks <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: <br /> Size of Tanks: 12.Si) 1Z 5-0 -J Z <br /> Treatment System <br /> Trenches s.f. <br /> Mound : 5 X 53./s,f. <br /> Gravel less 5.f. <br /> Chamber s.f. <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection, <br /> The undersigned hereby applies to the City of Orono for issuance of a septic system <br /> installation permit, agrees to do all the work in strict accordance with ordinances of the City <br /> and regulations of the State of Minnesota and certifies that all statements made on this <br /> application are complete, orrect. /1 <br /> 4 <br /> Signature of Applic Date: 781/� <br /> MPCA License No.: 1E. <br /> Staff Review: ❑ Accept Q Denied <br /> Reviewer: ' Date: <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W1(Applicatlons,License or Permit ApplicatIons}IPermIts\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 /2 <br />