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** ATTENTION APPLICANT ** <br />Fill in all appropriate blanks and check all appropriate boxes. j <br />I will be installing the following: <br />Tanks <br />Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br />Number of Tanks: <br />Size of Tanks: i <br />(list manufacturer) <br />1 h C)CC" <br />Treatment System <br />Trenches <br />s.f. <br />_ Mound <br />77 s.f. <br />Gravel less <br />S.f. <br />Chamber <br />s.f. <br />NOTE: The contractor is required to provide an As -Built of the system before the <br />final inspection. <br />The undersigned hereby applies to the City of Orono for issuance of a septic system <br />installation permit, agrees to do all the work in strict accordance with ordinances of the City <br />and regulations of the State of Minnesota and certifies that all statements made on this <br />application are complete, true and correct. <br />Signature of Applicant ,� i Date: <br />MPCA License No.: <br />Staff Review: �71 Accept ❑ Denied <br />Reviewer: Date: <br />Reason for Denial: <br />Comments (to be printed on inspection card): <br />(_'� -C;'(- /o <br />V:\(Permits)\Septic Permit Application - New Permit Fees 2009.doc <br />2/2 <br />