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CITY OF ORONO site evaluator /designer <br />2750 Kelley Parkway <br />P.O. Box 66 <br />Crystal Bay, MN 55323 <br />All quesuons must be anssvered. License fee jnd evidence of MPCA Cemf.cation-inuW| <br />anached. All applications are subject - a ten (10) day approval period. <br />V * *-• <br />1.Cr aC <br />/ <br />4. <br />X Site evaluator <br />Cenificate expiration JD£(L -----3J / <br />5 Type of certification held;X System designer <br />6.Have you ever performed site evaluation or design work m Orono before? <br />Most recent year / V~V^_____ <br />7.Have you ever had a license revoked? A/c?---- When? <br />Where? __________ ________________— <br />SUBMITTALS REQUIRED: <br />1. S 100.00 License fee. <br />~y 2. Copy of current MPCA Certificate <br />LICENSES WILL NOT BE PROCESSED UNTIL ALL ITEMS .ARE SUBMITTED <br />The undersianed hereby makes application to the City of Orono. Minnesota, <br />perform site”evaluation and septic system design subject to the laws of the State o mn <br />and the Ordinances of the City of Orono. <br />Applicant’sSignamre <br />CITY Staff recommendation: Approval <br />USE Reason for denial: _______ <br />qjsjLY City Council Action; Date _ <br />Date license mailed______ <br />kj(,*#.*iycj(c**j!c***iic>!i>«*>icA:i<:i«>!t****=!>*‘i‘*******’^*** <br />.1®Denial Date <br />Approved Denied <br />. « V <br />Business or trade name /-/ ' 5 _ <br />Business address ^ <br />Business phone V 7TI1 C- 3 ^--------Residence phone---------------------------------- <br />Name of applicant or company represema^e(s) aiding MPCA cemfication--------------