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mss;, <br /> City of Orono FOR CITY USE ONLY <br /> V,04,0 PoBoxss 7/ / q ZDI y— DO 7O 2— <br /> 2750 Kelley Parkway Date Received: 7 t' Permit# <br /> 1 Crystal Bay,MN 55323 �0 J C <br /> IL. (952)249-4600 Amount: $ <br /> yF <br /> I SH c3,„t <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 /> 5446344°'01"6(15 <br /> 6�s <br /> Job'S e:`/aa... ePI4 `i.F a >a'Al +,�i� e vc V • �� <br /> Site Address: Z 3 Ci'() but /Lv2.ci /id L L1/2/t1 i. <br /> Owner: , L EF ,-1 PA LZ(14 1;21,-)-1-4 a- Mailing Address: /g/,i7t 31-5T d 1,17" Ai <br /> City: l/-'/Lf/-'lzLt1-l- Zip: z 5L/`I-7 <br /> Home Phone: Alternate Phone: <br /> s r '7 c .yip.t;t<^\ "#tk.,�r ,z „ ^, <br /> ' : j�� 1 7a 3 1, Els t 1aF<i �t q a <br /> . � `e �t>�:'Y, aE71�t ,s ait: ,...�L.J>:�:'.ca „a.7�:t` .a 3Cr,'rkk+*1,a.�,,.u:i <br /> Contractor/App.: p,2,L 1211i.:i 1=Y 4ivl4 I"i/LL-7 Contact Person: StL zit, i-?/.41Zi4: <br /> Address: 34-I "it) /ttLitU r1/ /24:14cj Z/ State License #: I es <br /> City: /t-/i4ciLJZ Zip: 5 5 3 44 Expiration Date: ,312/fie/S' <br /> Phone: 13i) 95-S- -31/ Alternate Phone: /41z)z) !/6S--L/3 - <br /> 54 Residential ❑ Commercial ❑ Other <br /> uy:.R moi' . o *z}Y3 �f :.:1: <br /> < k :::v ,, S sf. [� y <br /> `,��M;��rF 4pv� dr ., ���a .-a�.Cz�k .,tis ,, a�� .r ., •d__ . � ,,. �..ra�b ., o ... <br /> New or Replacement System $200.00 rib f <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ 76S-1;L:: <br /> W:\(Applications,License or Permit Applications)\Permits\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />