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C,.Wl Ilny. Minn,M.m MAXI <br />UPIIJnly; A g'IN IN' - 413 7M? <br />ASSISSRG <br />SEPTIC SYSTEM INSTALLERS <br />LICENSE APPLICATION <br />All questions must be answered. ..iccnse 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 Ato a ten (10) day approval period. <br />A <br />1. Business or trade name P earhi, Of4et Y-W/.IS{G <br />2. <br />Business <br />address -57) ,-1 <br />/,i 1*-) 177kClPpk"c <br />f_S_35% <br />3. <br />Business <br />phone LI%q-4.34 3 <br />Residence <br />phone <br />4. Name of applicant or company representative holding MPCA <br />5. Type of certification held: Installer X_ Pumper <br />Site evaluator System designer <br />Is this a Provisiona—Certificate? Certificate No. C79 <br />6. If no Certificate is held, provide evidence of attendance at <br />one of the On -Site Sewage Treatment Workshops held immediatel <br />prior to the current construction season. <br />7. Have you ever held a Septic System Installer license in <br />Orono before? -�_ Most recent year 1M <br />B. Have you ever had a license revoked?/1,p_ When? <br />Where? _ <br />9. Do you do Municipal Sewer hook-ups? Yes_ No X <br />SUBMITTALS REQUIRED: <br />i' 1. $25.00 license application fec. <br />2. $2000.00 license and permit bond naming City of Orono as <br />py�obligee. The State Plumbers Bond will not be accepted. <br />,a, fjn'�!g $10-50-100,000 minimum Certificate of Insurance. <br />_ 4. Copy of current MPCA Certificate or evidence of attendence <br />at On -Site Sewage Treatment Workshop held immediately <br />prior to current construction season. <br />-X-604i�2fkc1, ['G ntpo._)W.IIIc„ttn,�!,c-� /�:-.I-!�. <br />c//. Cttr.a IGms. tiQ.. <br />LICENSES WILL NOT BE PROCESSED UNTIL ALL TTL S 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 r .ic <br />systems, and/or pump out septic tanks, subject to the _aws <br />of the State of Minnesota end the Ordinances o� the City of <br />Orono..l <br />Date ,�.� �- Applicants Signature 1),1'> ) 4 �idj z <br />J <br />CITY Staff recommendation Approval_ Denial J- Date N PS-F.'7 <br />USE Reason for denial: <br />ONLY City Council Action Date Approved Denied <br />Date license mailed <br />