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CITYof OUOXO <br />(612) 473-7357 <br />Post Office Box 66 <br />Crystal Bay, MN 55323 <br />i : <br />1?^ <br />SEPTIC SYSTEM INSTALLERS <br />LICENSE APPLICATION <br />rAPR 3 0 •'.CC.X <br />All questions rr.ust be answered. License fee, bond, certificate of <br />insurance, and evidence of MPCA Certification nusr be attached. All <br />applications are subject to a ten (10) day approval period. <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />Business or trade -.ame r’T^C'/^ ^i^^ <br />Business address ^ <br />Business phone 3 iS' Residence phone ^ ^_ _ _ <br />Name of applicant or company representative holding MPCA <br />certification Pit/h'p ^ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ <br />Type of certification held: Installer _ _ _ _ <br />Certificate expiration date <br />Pumper <br />Have you ever held a Septic System Installer license in <br />Orono before? Most recent year 19^ <br />■/' <br />Have you ever had a license revolted? <br />Where? <br />f\Io When? <br />7 T V *'C M c r'ijn <br />u 1 » I c'l u'ni.'MtJ' <br />Do you do Municipal Sewer hcok-ups? Yes <br />Do you pump out septic tanks? Yes _ _ _ <br />rri;.*i/*r "rTiTI L'> I aui. <br />No <br />No f T M <br />dl 4. t.'W V W <br />r» f rcMi/j. \futr <br />VI L. <br />• V’. <br />c-.} <br />wi'* vv <br />ocrcT/jT^ ruMifi' vmft f nfitfii f Ul/ <br />SUBMITTALS REQUIRED: <br />wwi iTv 4 <br />/U /7A .VT/ <br />1. <br />3. <br />i^4. <br />$50.00 License application fee. — jjnii <br />$2000.00 license and permit bond naming City of Orono asj5p,/•/®TT <br />obligee. The State Plumbers Bond will not be accepted. J <br />$50-100-300,000 minimum Certificate of Insurance, <br />Copy of current MPCA Certificate. <br />LICENSES WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTED <br />List persons other than applicant who are authorized by you to apply <br />for permits under your license __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _- <br />The undersigned hereby makes application to the City of Orono, <br />Minnesota, for a license to install and repair septic systems, <br />and/or pump out septic tanks, subject to the laws of the State of <br />Minnesota and the Ordinances of the City of Orono. <br />Date '2^'' ? *3 Applicant's Signature _ _ _ _ <br />CITY <br />USE <br />ONLY <br />Staff recommendation Approval <br />Reason for denial:w Denial Date <br />City Council Action Date <br />Date license mailed <br />Aonroved Denied