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of� I N� � 1'rYe(al 14n.V. Minnrwiln <br />NI'lI,U1tiGh /.(►tii�l; - 4737357 <br />ASSLSSING <br />SEPTI L SYSTEM INSTAL1,ElR< <br />LIC:I'NS_" APPLICATION <br />L,ond, certificate <br />All queStl�ns must b(� answered. License fee, <br />of in;;urance, and evidence of MPCA Certification or Home Sewage <br />Treatment Workshop attendence must accompany this application. <br />All applications are subject to a ten (10) day approval period. <br />1. Business or trade name /IRL <br />2. Business address i �z-7 AA-1A4A(hL /4VA <br />3. Business phone �% j - gll() 3 Residence phone <br />4. N&me of applicant company_ repre3entative holding MPCA <br />certification 4> _ <br />5. Type of certification hell'_ Installer Pumper <br />Site evaluator System designer <br />Is this a Provisional Certificate? 2D, . Certificate No. <br />6. If no Certificate is held, provide evidence of attendance at <br />one of the On -Site Sewage Treatment Workshops held immediatell <br />prior to the current construction season. <br />7. Have you ever held a Septic System Installer 'iccnse in <br />Orono before? *_ Most recent year 1QPL <br />8. Have you ever had a license revoked? Ll,? Wren? <br />Where:' <br />�. Do you do Municipal Sewer hook-ups? Yes-4- No <br />SUB TTALS REQUIRED: <br />1. $25.00 license application fee. <br />2. $2000.00 license and permit bond naming City of Orono as <br />obligee. The State Plumbers Bond will not be accepted. <br />$10-50-100,000 minimum Certificate of Insurance. <br />4. Copy of current MPCA Certificate or evidence of attendance <br />at On -Site Sewage Treatment Wcrkshop held immediately <br />prior to current construction season. <br />':-V; LICENSES WILL NOT HE PROCESSED UNTIL ALL ITEMS 1?RF. SUBMITT'- <br />u <br />List persons other than applicant who are authorized by you to <br />apply for permits under your license��,�� <br />-- Lt--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 />_ _ 1p ''. <br />Date //�atGN Applicants Signature <br />Staff. recommendation Approval `Denial Date.!Atrss_ <br />CITY Reason for denial: __ —.-- <br />USF City Counc±.l Action 1)-3te Approvod Donied <br />ONLY Date licvj,_c mailed <br />