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Poet Office 11 +x W) <br />IT��fa ��j� ���(� Cryxtal Hay, hlinncr,,.tn SEPTIC SYSTI'.M INSTALLI RS <br />`r LICE:NSE APPLICA':ION <br />BUILDING t 70NING - 473.7357 <br />- ASSESSING - All questions gust be answered. License fee, boncl, certificate <br />of insurance, and evidence of MPCA Certification or -Home Sewage <br />Treatment Workshop attendance must accompany this application. <br />All. applications are subj,!ct to a ten (10) day approval period. <br />v , <br />` 1. Business or trade nary,. <br />2. Business address r I /^]�. L U <br />3. Business phone _ Residence phone 7y- jl4j <br />4. Name of applicant or co;:ipan reyresentative holding MPCA <br />cent.:f ication ) - <br />S. Type of certificate n held: Y_ Installer Pumper <br />Site evaluator _System designer <br />Is this a Provisional-:'ertif.icate? )kl� Certificate No.� <br />6. If no Certificate is I..11d, provide evidence of attendance at <br />one of the On -Site Se%,ige Treatment Workshops held immediately <br />prior to the current r )nstruction season. <br />7. Have you ever held a S tic System Installer license in <br />Orono before? 4-6 Mos-. recent year �.4_ <br />8. Have you ever had a 1is e revoked? ,44,, When? <br />Where? <br />SUBMITTALS REQUIRED: <br />1. $25.00 license appli( tion fee. <br />2. $2000.00 license and ermit bond naming City of Orono as <br />obligee. The State Lumbers Bond will not be accepted. <br />3. $10-50-100,000 minimt_i Certificate of Insurance. <br />4. 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 Ordinances of the City of <br />Orono. <br />Date. <br />Staff <br />recommendation <br />CITY Reason for denial: <br />USF City <br />Council Action <br />ONLY <br />ONLY Date <br />license. mailed <br />Applicants Signature <br />�. )roval_ Denial Dafe��- —J-V <br />Ap F- I <br />Date Appro�e��-T Denied __ <br />