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C1111'a Y of 0K3N0 <br />,...1 lu.. u'. e. <br />Crystal II.Y. Mine wail <br />SEPTIC SYSTEM INSTALLERS <br />LICENSE APPLICATION <br />BUILDING e'/.INN we - 473-7357 <br />MSMING <br />All questions must be answered. License fee, bond, Certificate <br />of insurance, 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 />i <br />1. Business or trade name <br />J � <br />2. Business address <br />3. Business phone Residence phone — <br />4. Name of applicant or com any representative holding MPCA <br />certification-f•!V1� I��t;v <br />�J� <br />S. Type of certification held: Installer _ Pumper <br />Site evaluator System designer Is this a Provisional Certificate? Certificate No. 00 8 <br />V4N44ftet� PY /VPs /0 30 <br />6. If no Certifi ate is held, provide evidence of attendance at <br />one of the On -Site Sewage Treatment Workshops hid immediate) <br />prior to the current construction season. <br />7. <br />8 <br />J <br />Have you ever held a Sertic System Installer license in <br />Orono before? )brl- Mosc recent year _ _ <br />Have you ever had a license revoked? _N,, When? <br />Where? _ <br />Do you do Municipal Sector hook-ups? Yes No <br />BU}.SMI,TTALS REQUIRED: <br />✓y' /11. $25.00 license application fee. fie: 9 SS% <br />7 2Y $2000.00 license and permit bond naming City of Orono as <br />obligee. The State Plumbers Bond will not be accepted. <br />V 3r $10-50-100,000 minimum Certificate of Insurance. <br />Copy of current MPCA Certificate or evidence of attendance <br />at On -Site Sewage Treatment Workshop held immediately <br />prior to current constrt.-_tion 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 ..ut septic tanks, subject to the laws <br />of the State of Minnesota and the Ordinances of the C'ty of <br />Orono. / ,1 7 <br />Date <br />Applicants Signature <br />Staff recommendation Approval Z Deni-4d _ Date (O 5&-�iky <br />CITY Reason for denial: <br />USE City Council Action D.te _Approved Denie <br />ONLY Date license mailed <br />