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CITY OF OV = APPLICATION FOR UTILITY PERMITS <br />Box 66 (1335 So Brown Rd) f �' u SEVER HATER WELL <br />Crystal Bay, MN 55323 <br />�ef�lfflff/IIARAAA!!#A#AAAA##!!lfAf###AA!!A!!A!#f#AA#AAAfAAAAAAAAAAAAAAA!#! <br />General lastsuotiasa <br />1. Yon may apply for utility permits by mail or in person at the City offices. <br />2. Mailed in applications are subject to the postage and handling fees shown below. <br />Permit cards will be sent by return mail the sans day the application is received. <br />3. Permits are not valid until you receive a permit card. <br />4. Work must not begin unless the permit card is available on t%e job site. <br />5. Utility connection permits may be issued to licensed contractors only. <br />6. Contact the City offices for utility stub as -built locations. DO NOT EXCAVATE IN ANY <br />STRZZT AND DO NOT TAP ANY MAIN without express approval of the Public Works <br />Department. Issuance of a permit does not grant this approval. <br />7. All work met be done in accordance with State Code requirements. <br />S. All work must be inspected before it is covered. Call 473-7357. 24 hout notice <br />required. <br />#AA#AA#A#f##!WAWA#A#AA#!!#fAA+fAA!!A!A!#IAAAAIAAAAAIAAA!#fAAAlAA!lIAAAIAIAAA <br />JOB SITS ADGMSS: Vr <br />occupancy Types Residential Commercial <br />01N 18 NMI `%\ �, Al I(( Lj ti Phone No.: <br />Mailing Address: 1 7 o • r - .L City: <br />ca RACMIS N 31 _�C V �L. ( BusNo.: 179 } ' <br />Nailing Addresss :�.c c.� �� / City: No.! <br />Master Plumber's State License No.: City Cert. No.: <br />AffIfAAAAffffflAAA!#Al##f!!#f######A A A#AlAAA#AA!###AAA ! #! A <br />PERMIT TYPS AM M CALCULATION <br />I ZCIPAL SEWER couna !'ION ($30.00 per stub) $ <br />pipe sise inches; material PVC (on sand fi 1 ; ' cast iron <br />SAC Charged 0.00) must accompany all sewer permit applfcations unless <br />prepaid. If not prepaid, a sewer connection permit will not be issued. <br />I ZCItAL Us= (Ar r or, ( $30. 00 per stub) $ <br />pipe gist inches; :aaterial copper; other <br />WATER IIg= must be picked up an ppaid for at City Hall. <br />(5/80 Peters - $95.001 3/40 meters - $130.00) <br />PRIVWN 10" INSTALI ATIONS ( $ 30.00 per job) $ <br />Check: Mton <br />Replacement Repair an onment <br />Casing a se:Inches(Installof new/replacement well covers abandment of old well, <br />well Abandonment - not concurrent with installation cf new/replacement <br />well requires a separate permit) <br />REQUIRED minimum setbacks from drainfield and septic tanke - 75' <br />CALL FOR A SITE LOCATION BEFORE DRILLING <br />Upon completion, City must be sent a copy of State well Record. <br />##AAAA#!A###AAA#A###f!A#!AA##A#!A#AAAA#A##!#fAAAAA!#f!####A####AAA#A!A##### <br />1. Sabtotal of above permit requested <br />$ <br />2. State Surcharge .50 <br />The State Building Code Division Surcharge o 0 per perm t muat e <br />included foi- each well, sewer and water connection permit requested. <br />3. postage a dandling (only mail -in applications) $ 1.50 <br />4. TOM pWmIT FM (add lines 1-3 above) $ <br />!####AAIAAflellff##AAAAfAA!###!A##AA#AAlaaaAA!!!A!!A AAAA A#A♦#A#!!!##!!A <br />The undersigned hereby applies to the City of Orono for issuance of a utility Permit, <br />agrees to do all work in strict accordance with the ordinances of the City and the <br />regulations of the State of Minnesota, and certifies that all statements made on this <br />application are complete, true and correct. <br />_T <br />�-IC <br />Signature of Applicant: , 4; 1 W `` �L `. Date:� <br />