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C �, Cit of Orono FOR CITY USE ONLY <br /> ,��' Po Box ss q `q (`"; 2750KelleyParkwayDate Received; /Z(/JO Permit# 01010-00CrystalBay,MN55323 !��}]�o$yc (952)249-4600 Amount: $ 9 `et <br /> CITY OSSM AP <br /> (All OF permits mustRONO be approved-p by theSEPTIC On-SiteYSepticTEManager and/orPERMIT Building Official)LICATION <br /> : s`�r `. ,,as�,�'�t'1:::: <br /> ir t,7 <br /> c 3, :81 1 e V. 4. <br /> Site Address: "7 S I � ( 0 c.v b roc, �= 2_ - <br /> 1 I � <br /> Owner: Di c i�v-"� e-� <br /> � Mailing Address: %/7 5 (..,4(..,4 /(0,<,6 kckb�� -- <br /> City: Y-erg-., Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/App.: c1 c s S <br /> � y `� 5 Contact Person: ,, f2--4-- <br /> Address: z_L.- 3 z '=2 5.1- Sz �f2' <br /> State License-W-6. t- (.e `i 0 <br /> City: /kv'n't^---; Zip: -'-.-C-3 L: 5 Expiration Date: 1(--1-- \t <br /> r 1( 6 /2 6g'S q5-5-C) <br /> Phone: 73-Li7 -(76 z--• Alternate Phone: <br /> 77-1'1.,: ! a , - a ff -- ' , , „, '` ,;:: `F2i7,,,,,,,.-,-;.�„ �' -,ate`" <br /> � _..�Y �..'� ti:�� re.�.. �u�i..1:- <br /> �a..a�.t.., ��l ��..,,�oi�i �s ,�. m..,.��.�s..�.n._�....»�. ,... m�?i..� �a <br /> Residential ❑ Commercial ❑ Other <br /> .:", � , ".. ...8 ". ' : ,""dd',..�'- a._ .�. . . a L. 'i.:44A."'`7 l n T �`r, `t ' � <br /> New or Replacement System $200.00 Z c) v <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ 2_ v 5 - <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 1 / 2 <br />