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�� <br />CITY <br />011oINT) <br />O!!icrs at: 1]3S D:t•::� Fn.u! !cut! <br />J:.,,Iiny r.tBay. 1. o. l�oK <br />of, <br />Crystal nay, rt: 55]2] <br />Phonc: 47]-7]57 <br />SEp,;IC 5Y,,%':1;:;. J:;S'T;%LL1-o11\S <br />LICEPSL' 'M'PfI0%tf0': <br />All questions must 116 answered. License fee, bond, certificate of <br />insurance, and evidence of MPCA Certification or )come 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 r•ame—c-6yer- AW 6c), _ of C <br />2. Business address f?0i �� rtHt� t 3�0 <br />3. Business phone Residence phone SK#K� <br />4. Name of applicant or company representative holding_ MPCA certifi- <br />vatic-1 b `t LG,�tenCe l/`k 4101i <br />5. Type of certification held: V Installer Pumper <br />Site evaluator System designer <br />Is t}:is a Provisional Certificate? CERTIFICATE N0. S y2 <br />6. If no Certificate is held, provide evidence of attendance at one <br />of the On -Site Sewage Treatment Workshops held immediately prior <br />to the current construction season. <br />7. Have you ever held a Septic System Installer license in Orcnc <br />before? Mlost recent year <br />8. Have you <br />ever had a license revoked?AD-When? Where? <br />SL'E'•SITT LS REQUI:ttrD: <br />i <br />1. $25.00 license application fee. <br />2. $2,000.00 license and permit bond naming City ct Or•lno as <br />obligee. The•State Plumbers Bond will not be accepted. <br />Z3. $10-50-100,000 minimum Certificate of Insurance. <br />x4. Copy of current MPCA Certificate or evidence of attendance at <br />On -Site Sewage Treatment Workshop held immediately prior to <br />current construction season. <br />LICENSES E'ILI. NOT BE PROCESSED UNTIL ALL ITEMS ARE SUBMITTED. <br />List persons other than applicant who are authorized by you tc apply <br />for permits under your license <br />The undersigned hereby sakes application to the City of Orono. Minnesota, fcr llcense to install ant <br />repair septic systems, and/or pump out septic tanks, subject to the laws a;f the State of M:nn.csota <br />and the Ordinances of the City of Orono. <br />DateA'20_1__?!� ^ Applicants signatu:e,�v---- <br />Staff reconr:+(ndation Approva I _�' Denial Date: <br />F•aa50n for denial: <br />City Council 1.114.r. Lat.: Afptova•J <br />GAtr 11(l: l SII.,t . . <br />OFFICE USL ONLY i <br />