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CITY OF ORONO <br />2750 Kelley Parlc^vay <br />P.O. Box 66 <br />Cr%-stal Bay, MN 55323 <br />. T :cense fe* and evidence of MPCA Certification must be <br />All questions must be ''’aS) dav approval period.attached. All applications are subject to a tea (l I . FF <br />^ k'Lf</* 'V < -i- ■_________Business or trade name / )/7/K'? n*- < ^ ----- 7*^ <br />’—** ___________aVef______________________ <br />1. <br />Business address n ^'s:^— <br />sacs:)Rijiiowr ph( <br />(city/(zip) <br />J. <br />4. <br />5. <br />6. <br />rpnrpcpmative(s) holding MPCA certification____ <br />*........................... <br />Tvpe of cenificaiion held: _j\_ Site evaluator <br />Certificate e.xpLration <br />Have you ever performed site evaluation or design work in Orono before? <br />Most recent year </_---------- <br />>C System designer <br />7.Have you ever had a license revoked? t^t2- <br />Where?------------------------------------------- <br />When?C ;*A ; J <br />SUBMITTALS REQLTRED: <br />>/ 1. SIOO.OO License fee. <br />2. Copv of current MPCA Certificate. <br />ISA? *• «? <br />COOi <br />r ^ ^ 4 ^ <br />UCENSES \V1LL NOT BE PROCESSED UNTIL ALL ITEMS AM SU^^UTTED <br />The undersigned hereby makes application to State of Minnesota <br />perform site evaluation and septic system design subject to the laws oi ^ <br />and the Ordinances of the City of Orono. <br />p-ar,. d-::) ^ Applicant’s Signature war------^ <br />............’*’*'T7^T*De*iriT******"**"^^Staff recommendation: ApprovaluemaiCITY <br />USE <br />ONLY <br />Reason for denial: _____ <br />City Council Action: Date <br />Date license mailed <br />Approved Denied