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(CITY Of ef"_MONO ,r,r•..::........ , <br />Pholw : t 71- 7 )„ <br />All qucs,ions r:u;t be answered. license fee, bond, certificate of <br />insurance, and evidence of MPCA Certification or Dome Sewage Treat- <br />ment Workshop attendance must accompany this application. All appli- <br />cations are subject to a ten (10) day approval period. <br />1. Business or trade name —Wsax� PL86 Go ),J <br />2. Business aedress <br />3. Business phone Ci33 Z'r2,_ I <br />h ifiUsrbVq' \'Q. rsL' Vo <br />Residence phone <br />4. Name cr applicant or conn.pa.ny representative holding_ M11CA certi i— <br />c a t l c :'. u L (5Vu«- (. CrYJ <br />5. Type of certification held: Installer Pumper e;ltIC_ <br />Site evaluator System designer <br />Is this a Provisional Certificate? CEFTIFICI:TE N0. 0�8� <br />J � • w�F 1lt.n•.rtt w/PC %4 <br />6. If no Certificate is held, provide evidence of attendance at one <br />of the On -Site Se%..ace Treatment 1•;ori;shops held inur.ediately prior <br />to the current construction season. <br />7. Have you ever held a Septic System Installer license in Orono <br />before, yL3 S _ Most recent year 1�1-j <br />8. Have you ev, nad a license revoked? 0'0 When?, Where? <br />SUP.!•jITTr.LS i•.QUIicEG: // <br />_.-�---•--------�_ .-----._____..._..! <br />L-)&l- $25.00 license application fee. �co 90� <br />QL2. $2,000.00 license and permit bond naming City of Orono as /9g`% ReND /S <br />obligee. The State Plumbers Bond will not be accepted. coNriti r� <br />©-_3. $10-50-100,000 n;- :-,am Certificate of Insurance. <br />Ole_4. Cody or current Certificate or evidence of attendance at <br />On -Site Sewage T, ,nent Workshop held immediately prior to <br />current construct,t.r season. <br />LICENSES 1.7ILL NOT BE PROCESSED UNTIL ALL ITEMS ARL SUBMITTED. <br />List persons other than applican who are auAorized by you to apply <br />for permits under your license � <br />The undersiSned hereby wakes application to the City of Orono, 71.nsots. for license to .stall and <br />repair septic systems, and/or pump out septic tanks, subject to the laws of the State of Minnesota <br />and the Ordinances of the City of Orono. <br />Applicants signature •di c�� <br />Staff reeowmendation Approval: x Denial:Date: <br />Reason for denial! T — <br />Clty Council J.ct7arr ,.at• ._ _ --_ /•i; ru�•c•J Ut•nie@: <br />1 iear.:..::. •• <br />- OFFICE USE oimY <br />Date <br />