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I '�,t % i 1: -W. -- <br />�ti,i�6 1 Q➢ <br />Cryntnl Bay, Minnegota 55323 <br />Itl'11-I)ING & P)NING — 473.7357 <br />ASM'SSING <br />SRPTIC SYSTEM INSTALLERS <br />LICENSE APPLICATION <br />All questions must be answered. License fee, Lo nd, certificate <br />of insurance, and evidence of MPCA Certification or Home Sewage <br />Treatment Workshop attendence must accompany this application. <br />All applications arc subject to a ten (10) day approval period. <br />I- Business or trade name ( _ �J�/�/- 1411 Co _Tc <br />2. Business address S1-X LE ccyne ( <br />3. Business phone 710 gT16 Residence phone Su�- <br />4. Natne of applicant or compan representative holding MPCA <br />certification j "01% `US • tf- <br />5. Type of certification held: Y, Installer Pumper <br />Site evaluator System designer <br />Is this a Provisiona—Certificate? Certificate No. 101/0 <br />6. If no Certificate is Meld, 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 license in <br />Orono before? most recent year g-(o_ <br />8. Have you ever had a license revoked? JAL When? <br />Where? <br />�. Do you do Municida'_ Sewer hook-ups? Yes_ No <br />SUBM TALS REQUIRED: <br />c. 1. $25.00 lice,.se application fee. <br />2. $2000.00 license and permit bond naming City of Orono as <br />obligee. The State Plu:abers Fond will not be accepted. <br />✓ 3. $10-50-100,000 minimum Certificate of Insurance. <br />4. Copy of cuz re--t MPCA Certificate or evidence of attendence <br />at On -Site Sewage Treatment Workshop held immediately <br />prior to current construction season. <br />LICENSES WILL NOT BE PROCESSED UNTIL ALL rEMS ARE SUBMITTED. <br />List persons other than applicant who are authorized by yuu 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 I- / 3- J_ Applicants Signature <br />Staff recommendation Approvat�/�K Denial Date `�� /- � <br />CITY Reason for denials <br />USE City Council Action Date Approve Denied <br />ONLY Date license mailed <br />