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** ATTENTION APPLICANT ** <br /> � Fili in all a ro riate blanks and check all a ro riate boxes: <br /> I will be installing the following: <br /> Tanks <br /> ��ecast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: � � <br /> Size of Tanks: � ��� ( �Uc� (�,?c�c.:� <br /> Treatment System <br /> /Trenches s.f. <br /> �� Mound ��� s.f. <br /> Gravel less s.f. <br /> Chamber s.f. <br /> Final Cover/ Top Soil <br /> to be borrowed from site (show location on site plan) <br /> trucked in <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 .,,1� Date: ,S ��;�-�� <br /> MPCA License No.: �� (}(,, <br /> Staff Review: Accept ❑ Denied <br /> Reviewer: _ ��t,�ju-� ���� Date: �' ��-C� <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> V:\(Permits)\Septic System Permit Application.doc <br /> 2 � 2 <br />