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' CI'1'Y UF ORONO APPLICATION FOR UTILITY 1'ER11�I1'1'S <br /> 13ox GG (2750 Kelley Parkway) S�WER/WAT�R <br /> Crystal Bay, MN 55323 <br /> GENI;RAL INFORMA'f10IY <br /> 1. You may apply for utility pennits by mail or in person at the City officcs. <br /> 2. Mailed in applications are subject to thc postage and handling fees shown bclow. Pennit cards will be sent by <br /> return mail the same day the application is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. Work must not begin unless tlie permit card is available on the job site. <br /> 5. Utility connection permits may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department(473-7357)for utility stub as-built locations. DO NOT EXCAVAT'G <br /> 1N ANY STREET AND DO NOT TAP ANY MAIN without express approval of the Public Works <br /> Departmcnt. Issuance of a permit does not grant this approvll. <br /> 7. All work must be done in accordance witll State Code requirements. <br /> 8. All work must be inspected before it is covered. Ca11473-7357. <br /> 24 hour notice required. <br /> JOBSIT�ADDI�SS: 3 " D � � <br /> Occupancy Type: I�csidenti� Commercial <br /> Owner's Name: � � � " Phoiie Number: ����- - f � _-'s Y <br /> Mailing Address. ` ���� - �' � City: 5 � �:> � ��. 7�p: <br /> Contractor's Name: �/ �- , �- Phone Number: �,1�� /y ys ' <br /> Mailing Address: � .� 3 S— City: �= " 7�p: �-5� ZS <br /> P�RMIT TYPE <br /> Municipal Sewer Connection ($35.00 per stub) $ <br /> pipe size �/� inches; material_�PVC (ou saiid fill); cast� iron <br /> SAC Charge($850.00)must accompany all sewer petmit applications unless prepaid. If not prepaid, <br /> a sewer coruiection permit will not be issued. <br /> Municipal Water Connection ($35.00 per stub) $ <br /> pipe size inches; material copper; other <br /> WA'I'LR ME'I'ERS must be picked up and paid for at City I-lall. <br /> (5/8" ineters = $139.00; 3/4" meters = $191.00; 1" meters = $247.00) <br /> Separate Plumbing Permit issued for water meter. <br /> Watcr meters must be set and sealed by Orono Water Departcnent(473-7357)upon completion <br /> of mcter install�tion. <br /> RCQUIREll minimum setbacks from draiiirield and septic tanks = 75' <br /> RCQUIRCD setback from sewer line = 20' <br /> PF,IZMIT FCI; CALCULA'TION <br /> 1. Subtotal of above permit requested $ "'` � � <br /> ^ 2. State Surchar�e $ .50 <br /> �, The State I3uilding Code Division Surcharge of$.50 per permit must be <br /> , ; <br /> ^ included for each well,sewer and water connection permit requested. <br /> '���� 3. Posta,ge & Handling (Only mail-in applications) $ 1.50 <br /> 4. TOTAL P�RMIT FLE (add lines 1-3 above) $ ; ? ' <br /> 1'he undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do <br /> all work in strict accordance with the ordinances oF the City and the regulations of the State of <br /> Minnesota, and certifies that all slatements made on this application are complete, true and correct. <br /> Si�;naturc ofApplicant:����/���-�'a�Ii��� Date: �'' �S ' �� <br />