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-EPTIC SYSTEM PERMIT APPLICA TON - PAGE 2 <br />Permit Type i Pees (check one) <br />New Construction, Full System $100.00 . . . . . . . . . . . . . <br />Repair or Replace Existing System $50.00. . . . . . . . . . . . <br />0.50 State surcharge added to above permit fees <br />SEE FEE SCHEDULE FOR NON-RESIDENTIAL PERMIT FEES <br />DO NOT MAIL PAYMENT WITH THIS APPLICATION <br />ZOTE: Applicant must initial all spaces. Fill in all appropriate blanks, <br />check all appropriate boxes. <br />Initial <br />1. I have received a copy of the system design including the <br />City of Orono Septic System Approval Cover Sheet. <br />_ 2. I will be installing the following: <br />A. Tanks: Precast Concrete Other Manufacturer <br />Tank Capacities: 1) gal. 2) gal. 3) gal. <br />B. Pump Station (if required) <br />Pump make & model (attach pump curve & <br />literature); system design requires vpm at feet <br />of head. High water alarm make & model <br />Outside electrical work to be completed by _installer <br />_electrician other Inside electrical work <br />must be completed by electrician. <br />C. Treatment System: <br />l Trenches: r s.f. <br />Depth of rock below pipe " <br />Drub Boxes <br />Distribution Box <br />Mound <br />Rock bed dimensions 'x ' <br />Sand bed dimensions 'x ' <br />Pressure Dist. Pipe Diam. " <br />Manifold Pipe Diam. " <br />D. Final Cover/Topsoil to be: borrowed from site <br />(show location on site plan) <br />trucked in <br />The undersigned hereby applies to the City of Orono for issuance of a <br />septic system installation permit, agrees to do all work in strict <br />accordance with the ordinances of the City and the regulations of the State <br />of Minnesota, and certifies that all statements made on this application <br />ire complete, true and correct. <br />Signature of Applicant: L.- L�a-u� - Date: /2 <br />4PCA Certification No.: -5 it <br />