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�4e2 <br /> 1 O City of Orono FOR CITY USE ONLY <br /> oP.O.Box 66 <br /> r� 2750 Kelley Parkway Date Received: '6O% i t Permit# <br /> NCrystal Bay,MN 55323 <br /> a (952)249-4600 Amount: $ r �� <br /> soy <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 /> , <br /> Site Address: t S ; 1 ©w <br /> Owner: (� r ( �0 Lk) 11^ AVS Mailing Address: , 'f(u w 0 S <br /> City: Zip: <br /> C-J-I• <br /> Heme Phone: -7 (0 3 S g� r 7 7 5 Alternate Phone: <br /> Cora ra pp`lcan ".Information: <br /> Contractor/App.: Contact Person. '5) <br /> Address: Z S L <br /> State License #: <br /> City: Gt/0j---"f''� Zip: -5-S-3 6 Expiration Date: <br /> Phone: 74, _L-Lf 7 S 17 ,6 2_-- Alternate Phone: 4.12 6 :9.5" 9��_6 <br /> ` k '.,. ? ': .M.. ; ', . r 'YPES OF OCCUPANCY <br /> Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES. ,n _4 ', � <br /> New or Replacement System $200.00 Z D M <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ 2 o <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />