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� , � <br /> ' - . <br /> SKETCH: Submit licensed site evaluation, design, sk tch and management plan with <br /> application. If substantial changes are made to the de ign during installation, a new design <br /> must be submitted with the date and designer's signat re prior to installation and inspection. <br /> Completed Site Evaluation .�dYes ❑No Date �d-��-�-� <br /> Completed Design Worksheets �Yes ❑No Date C d";d,�` �3 <br /> Compliance Inspection � )n� ❑Yes ❑No Date <br /> Management/Monitor Plan � es ❑No Date Approved <br /> AGREEMENT: I/We the undersigned, hereby make a plication for work described and located <br /> as shown herein. I/We certify that the information cont ined herein is correct and agree to do <br /> the work in accordance with the provisions of the Oron City Code and the State of Minnesota <br /> MPCA Rules 7080-7084. I/We further agree that any ans, specifications, or drawings <br /> submitted erewith are ccurate and shall become pa of the application. <br /> .,�-..� ., . <br /> �- �.� ��"�"-- !__ �- j�l <br /> Signature of k�6meo�iv�er or Agent Date <br /> PERMIT: Permission is hereby granted to the above n med applicant(s) to perform the work <br /> described in the above application. Any and all chang s to the approved design shall be <br /> reported to the designer and to the permitting agency p ior to the completion of the work. This <br /> permit is granted upon the express condition that the p rson to whom it is granted, and his/her <br /> agent, employees and workers shall conform in all resp cts to the Orono City Code and the <br /> State of Minnesota 7080- 7084 Rules. This permit ma be revoked at any time upon violation <br /> of said ordinances and codes. This permit expires on ecember 31 of the year in which it is <br /> issued. This permit, with all supporting documents, will become a permanent part of the <br /> property records on file at the Orono City Hall. <br /> Commu ty Development irector or Designee ate <br /> Return this Application to: <br /> Phvsical Address: Ma in Address: <br /> City of Orono Cit of Orono <br /> 2750 Kelley Parkway P Box 66 <br /> Orono, MN 55356 Cry tal Bay, MN 55323 <br /> Phone :952-249-4600 ww .ci.orono.mn.us <br /> Fax: 952-249-4616 am ck ci.orono.mn.us <br /> Septic Permit—Revised 7/8/2014 Page 2 of 3 <br /> I� I <br />