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SKETCH: Submit licensed site evaluation, design, sketch and management plan with <br /> application. If substantial changes are made to the design during installation, a new design <br /> must be submitted with the date and designer's signature prior to installation and inspection. <br /> Completed Site Evaluation 4Yes ❑No Date -' ),Z Fed-y /V <br /> Completed Design Worksheets PYes ❑No Date f--7-0 4/- ly <br /> Compliance Inspection LI Yes IA No Date 0fQ <br /> Management/Monitor Plan 1Yes ❑No Date Approved <br /> AGREEMENT: I/We the undersigned, hereby make application for work described and located <br /> as shown herein. I/We certify that the information contained herein is correct and agree to do <br /> the work in accordance with the provisions of the Orono City Code and the State of Minnesota <br /> MPCA Rules 7080-7084. I/We further agree that any plans, specifications, or drawings <br /> submitted herewith are accurate and shall become part of the application. <br /> ) /6 -IX <br /> Signature of Homeowner or Agent Date <br /> PERMIT: Permission is hereby granted to the above named applicant(s) to perform the work <br /> described in the above application. Any and all changes to the approved design shall be <br /> reported to the designer and to the permitting agency prior to the completion of the work. This <br /> permit is granted upon the express condition that the person to whom it is granted, and his/her <br /> agent, employees and workers shall conform in all respects to the Orono City Code and the <br /> State of Minnesota 7080— 7084 Rules. This permit may be revoked at any time upon violation <br /> of said ordinances and codes. This permit expires on December 31 of the year in which it is <br /> issued. This permit, with all supporting documents, will become a permanent part of the <br /> property records on file at the Orono City Hall. <br /> 7//k// <br /> Communit Development Director or Designer /Date <br /> Return this Application to: <br /> Physical Address: Mailing Address: <br /> City of Orono City of Orono <br /> 2750 Kelley Parkway P 0 Box 66 <br /> Orono, MN 55356 Crystal Bay, MN 55323 <br /> Phone :952-249-4600 ww,,v CI 010110 nut US <br /> Fax: 952-249-4616 arrack cni ci.orono mn.us <br /> Septic Permit—Revised 7/8/2014 Page 2 of 3 <br />