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a <br /> ** ATTENTION APPLICANT <br /> Fill in all,a ro' riate blanks check all ate' ro nate boxes.`= <br /> I will be installing the following: <br /> Tppks <br /> Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: <br /> Size of Tanks: 16 20 v <br /> Treatment System <br /> Trenches s.f. <br /> '7 Mound s.f. <br /> Gravel less s.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, true and correct. <br /> Signature of Applicant c c� Date: <br /> MPCA License No.: <br /> Staff Review: Accept ❑ Denied <br /> Reviewer: Date: I <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> yti 57 s- -ckil - <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 / 2 <br />