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CRT <br />'ey Of G <br />hR0 <br />j � a.l I7i U, 1, .).iw .wI <br />C►yRlnl Flny, Minn^nnla 5!,:323 <br />IiUII.UIN(; A ZONING - 473.7357 <br />ASSLSSIN G <br />SEPTIC SYSTEM INSTALLERf' <br />LICENSE APPLICATION <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 />1. Business or trade name <br />2. Business address A 777 `3 670 X-=3— P 01E�I� <br />3. Business phone /�%%" JQ�� Residence phone <br />4. Name of applicant or company representative holding MPCA <br />certification -7—iryl <br />5. Type of certification held: Installer Pumper <br />Site evaluator System designer <br />Is this a Provisional Certificate? Certificate No.eeW <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? )L.� Most recent year 56, <br />8. Have you ever had a license revoked? U V:hen? <br />Where? <br />9. Do you do Municipal Sewer hook-ups? Yes i\ 1'o <br />SUBMITTALS REQUIRED: <br />�1. $25.00 license application fee. <br />$2000.0U license and permit bond naming City of Orono as <br />obligee. The State Plumbars Bond will not be accepted. <br />3. $1.0-50-100,000 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 />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 out septic tanks, subject to the laws <br />of the State of Minnesota and the Ordinances of the City of <br />Orono. <br />Datc < - �Applicants Si1nature e <br />Staff recommendation Approval %�� C, nia� J _ Date <br />CITY Reason for dental: �f <br />USE City Council Action Data Approved -Denied <br />ONLY Date license mailed <br />