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is;#-V- <br />fe';-’' <br />fe-' <br />r <br />m <br />x>-' <br />pf <br />jn <br />S':.' <br />|^> <br />l*'“C-- <br />V*'; <br />K- <br />Kj:. <br />E; <br />A ’■ <br />fl’-* <br />^r:. <br />^?'. <br />H-. <br />v*V' ' <br />•;:v* ■ ■' <br />S;- <br />:i;’^ <br />■r^ <br />h'.H-* <br />■i- <br />'•h <br />* «CITYof ORONO <br />(612) 473-7357 <br />Post Office Box 66 <br />Crystal Bay, MN 55323 <br />SITE EVALDAT0RA>ESIGNER <br />LICENSE APPLICATION <br />^1 Q\jQ3tions inust te answered. License fee and evidence of MPCA <br />Certification must be attached. All applications are subject to a ten <br />(10) day approval period. <br />1. <br />2. <br />3. <br />4. <br />/’f/f rcf^ , y.i/C .Business or trade name <br />Business address <^5 /(/. <br />Business nhone Residence phone yr/- <br />r ? - sjJ -f ) <br />Name of applicant or company representativeCs) holding MPCA <br />(^gj^-tification M mi 'k ->-_ _ _ _ ___ _ __ <br />5.Type of certification held: ^ Site evaluator <br />designer. Certificate expiration -y/-9J <br />X System <br />6.Have you ever performed site evaluation or design work in <br />Orono before? rt^T Most recent year - <br />7.Have you ever had a license revoked? <br />VThere ? _____________________________ <br />When? <br />•, T V r-c r.r^QSiQLyi f- t VI Wl <br />L*y?JSkirc i'tCC TPCI AMniTuu ut I xiwu <br />j — j j \ A A A <br />SUBMITTALS REQUIRED; <br />X 1, $100.00 License application fee. <br />2. Copy of current MPCA Certificate. <br />f nf^ /1 W • V <br />i n/^ •A VV • Vrucr}(VI rVUM <br />c^ V (j VUAkiK vnjjrtvwv*. I fiiniTM I UU <br />If r» VO A A Ti f Of) i TQ]nr^-v V wvi MV A iv/i <br />04/0: <br />LICENSES WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTED <br />The undersigned hereby makes application to the City of Orono, <br />Minnesota, for a license to perform site evaluation and septic <br />system design subject to the laws of the State of Minnesota an <br />the Ordinances of the Citv of Orono. <br />Date _________ Applicant's Signature <br />Staff recommendation Approval <br />Reason for denial; <br />City Council Action Date <br />Date license mailed <br />Approved <br />1^;"'