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... .. . .. ..... I .. III I..:... <br />l;l'1 1 cif :►RO NO <br />u r:.tn ns. rr: rl;l LTCENSI, APPLICATION <br />wn,ne: m-usy <br />All questions must be answered. License fee, bond, certificate of <br />insurance, and evidence of MPCA Certification or Home 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 WAkrcs, "Ste. <br />2. Business address (gasp �7!/tuai J,;1LA) ,WIePlaiAI, 653.5% <br />3. Business phone yrpGrelet <br />-y3y3_-Residence phone 0 / -gmN3 <br />4. Name of applicant or company representative holding MPCA certifi- <br />caticnt/44& /�tLltttt� 1. <br />5. Type of certification held: _Installer _Pumper <br />_Site evaluator _System designer <br />Is this a Provisional Certificate? CERTIFICATE NO. <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 />41 to the current construction season.-W.1Jaikf ne(t5a)"JaEW0Wshop <br />7. Have you ever held a Septic System Installer license in Orono <br />before? n0 Most recent year <br />8. Have you ever had a license revoked ?,When? Where? <br />SUBMITTALS REQUIRED: <br />1-'1. $25.00 license application fee. <br />t--2. $2,000.00 license and permit bond naming City of Orono as <br />obligee. The Sta, bets Bond will not be accepted. <br />�- 3. $10-50-100,000 r._. Certificate of Insurance. <br />1t__ 4. 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 WILL NOT BE PROCESSED UNTIL ALL ITEm, ARE SUBMITTED. <br />List persons other than applicant who are authorized by you to apply <br />for permits under your license <br />TAe undersigned Iq«bY rate..,Pllcttlon to the City of Giant. mmnetete. for lice." t, install and <br />repeb Septic Syrians, and/or Pw0 out .entic rants. sublact to tM )a•s of the State a ..nna.ou <br />and the Ordinance. of ran City of O,ono. <br />Date - 0 9,)- Applicants signa <br />It"' reeoaaenda Uon A _ � <br />PP,awl: Lnl air eate �, <br />Susan toe Oeu,n 1: <br />City C..n111 1....... E..,. L11'r o.,1 1,r.. �r. <br />on. 1,ctr... , 1.: _ __. _. OFFICE USl: ONLY <br />