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SEPTIC SYSTEM INSTALLERS <br />LICENSE APPLICATION <br />CITY of ORONO C.r1N say, kemm..ml. mmfa <br />OtALDING A ZONING - 4731)51 <br />ASSUSING <br />All questions must be answered. License fee, bond, certificate <br />of insurance, and evidence of MPCA Certification or Home Sewage <br />Treatment Workshop attendance must accompany this application. <br />All applications are subject to a ten (10) day approval period. <br />1. Business or trade name�•/p�SvN Cr1(C/c�!/ <br />2. Business address ao Y (0 ( /Ys^Ok A o-; a %1,�/~ ' <br />3 Business phone 46%ice.17�% Residence phone GJS 3�ty0 <br />4. Name of applicant Gr company representative holding MPCA <br />certification IAOM�'•'�• Z N� <br />5. Type of certification held: Installer Pumper <br />Site evaluator System designer <br />Is this a ProvisionaYCertificate7 Certificate NoQ� <br />V Iz fl <br />6. If no Certificate is held, provide evidence of attendance at <br />one of the On -Site Sewage Treatment Workshops held immediatel <br />prior to the current construction. season. <br />7. Have ycu ever h9ld a Septic System Installer license in <br />Orono before? y� Most recent year <br />S. Have you ever had a license revoked? �J When? <br />Where? _ <br />0. Do you do Municipal Sewer hook-ups? Yes_ No <br />SUBMITTALS nGVuinou: <br />L� $25.00 license application fee. --' - <br />. $2000.00 license and permit bond naming C.ty of'O}0no as - <br />obliges. The State Plumbers Bond will not be accepted:-_: <br />✓� $10-50-100,000 minimum Certificate of Insurance.'` = <br />Copy of current MPCA Certificate or evidence of attendance <br />at On -Site Sewage Treatment Workshop held immediately <br />prior to current construction season. <br />LICENSES WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTED. <br />List persons other than applicant who are authorized by you to <br />apply for permits under your license <br />The undersigned hereby makes application to the City of <br />Orono, Minnesota, for license to install and repair septic <br />systems, and/or pump out septic tanks, subject to the laws <br />of the State of Minnesota and the Ordinnnc s of the City of <br />i Orono. <br />Data Applicants Signature '�° 4o'� <br />Staff recommendati Approval Denial Date <br />CITY Reason [or dcniall <br />} OYDBMLCity Council Action Date Approve _ Denis <br />Date license mailed <br />/ <br />