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CITY of OUONO <br />(612) 473-7357 <br />Post Office Box 66 <br />Crystal Bay, MN 55323 <br />SEPTIC SYSTEM INSTALLERS <br />LICEJISE APPLICATION <br />All questions must be answered. License fee, bond, certificate of <br />insurance, and evidence of MPCA Certification must 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 />a. <br />9. <br />Business or trade name _ _ _(^/7ro C? <br />Business address ^ <br />Business phone - 6 ">1'^— Residence phone _ _ _ <br />Name of applicant or company representative holding MPCA <br />Type of certification held: V Installer <br />Certificate expiration date /p - ^Ml. <br />01 CLi CHECX TL <br />Have you ever held a Septic System Installer 1 Lcens^iiiSiP7~'''HAfP(''^'^'' <br />Orono before? . /V.0 Most recent year _______ ft23i720 C(X)1 ROi TOS: <br />tr.i AAV •cr, <br />Vl"M/f Uw' <br />Have you ever had a license revoked? aZ O <br />Where? <br />When? <br />10/17 <br />%d/ <br />Do you do Municipal Sewar hook-ups? Yes <br />Do you pump out septic tanks? Yes _____ <br />X_____ No <br />No ^ <br />SUBMITTALS REQUIRED: <br />2L ^550.00 License application fee. <br />^•*^$2000.00 license and permit bend naming City of Orono asA^ <br />obligee. The State Plumbers Bond will not be accepted. ''r <br />JL 3 .i^ $50-100-300,000 minimum Certificate of Insurance, <br />4.^opy of current MPCA Certificate, <br />LICZNSBS 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 _ _ _LO /t \ jJ', K /< Q <br />\ <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 O^no. <br />Applicant's Signature ^_-^y o <br />CITY <br />USE <br />ONLY <br />Stafi r«coiwu«.ndation Approval / <br />J'aason for denial: ■' * <br />Denial Date <br />City Council Action Date <br />Date license mailed <br />Approved Denied