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a-' <br />CITY of ORONO Crystal Bay, Minnesota 55323 SEPTIC SYSTEM INSTALLERS <br />LICENSE APPLICATION <br />i <br />ih <br />■(uf;: <br />r- - <br />C-'- <br />■ <br />w: <br />*.<• <br />«:• <br />^7.i <br />•b"' <br />i- <br />;:iTY <br />asE <br />ONLY <br />building a zonin(; - 473-735 <br />assessing <br />^j^3. cju0stions must bG unswGrGd- Lj-CGFisg fG0/ bond, uGirtif^c^tG <br />of insurance, and evidence of r^CA Certification or Home Sewage <br />Treatment Workshop attendence must: accompany this application. <br />All applications are subject to a ten (10) day approval period. <br />riij\1. Business or trade name _ <br />2. Business address ///".’ <br />3. Business phone _ _ _ <br />V> SL <•/ <P yr ^ <br />y < f-3 . A'AJ, . <br />Residence phone <br />4 .Name of applicantor company representative holding MPCA <br />certification V _ _ _ _ _ _ _ _ _ _— <br />5. Type of certification held: )( Installer Pumper <br />Site evaluator /\ System designer _ <br />Is this a Provisional Certificate? Certificate No.<^^-Sjy <br />6 .If no Certificate is held, provide evidence of attendance at <br />one of the On~Site Sewage Treatment Workshops held immediately <br />prior to the current construction season. <br />7. <br />8. <br />Have you ever held a Septic System Installer license in <br />Orono before? Most recent year ^ f _ <br />Have you ever had a license revoked? When? _ _ _ _ __ <br />Where ? <br />10. <br />Do you do Municipal Sewer hook-ups? Yes <br />Do you pump out septic tanks? Yes X <br />No /J,p <br />No <br />SUBMITTALS REQUIRED: <br />ijiijOOOOO <br />01 QEH fh V'9 <br />A. $25.00 license application fee <br />77^2. $2000.00 license and permit bond naming City of Orono as ^ , <br />obligee. The State Plumoers Bond will not be accepted .^ip <br />$10-50-100,000 minimum Certificate of Insurance <br />4. Copy of current MPCA Certificate or evidence of attendence <br />at On-Site Sewage Treatment Workshop held immediately <br />prior to current construction season . <br />•''^TY u^iSHQLICENSES WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTfJjJ^^^^ OFFICE <br />12115QOOOO <br />List persons other than applicant who are authorized by'‘you ^rvj^ <br />apply for permits under your license _ _ _ _ _ _ _ _ _ _ _ _ _ _CHECH ft <br />otr a. <br />• VVnr A, <br />Cij 0 <br />The undersigned hereby makes application to the City <br />and repair sept Ik:Orono, Minnesota, for license to install and repair Sep <br />systems, and/or pump out septic tanks, subject to the laws <br />of the State of Minnesota and the Ordinances of the City of <br />Orono. <br />03/JL <br />Date <br />Staff recommendation Approval <br />Reason for denial: <br />Applicants Signature _ <br />Denial Date <br />City Council Action Date <br />Date license mailed <br />Approved Denied