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, � , <br /> � g�� City of Orono FO CI USE ONLY �� <br /> �,5 � P.O.Box 66 Date Received:� Z I Permit# �dl��b <br /> r1,,, 2750 Kelley Parkway <br /> �'t�,�� � Crystal Bay, MN 55323 �7��!'�� <br /> ���,�(���.$o (952)249-4600 Amount: $ �� <br /> CITY OF ORONO — SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> .lob S:rte ,�ner Iri�'"s „tc�r� ` " a °4�} <br /> : _ <br /> �� � % <br /> � E, , ,. � �.� ����t� ��.. �y�E,� ����G.; <br /> Site Address: �U �(,; ��q�-t��,� ��vC��� <br /> Owner: � � �' � l--`�`�' ���v�- Mailing Address: �>� ���--r� <br /> City: L:.> � � ;�L Zip: �`7 ;��"'� <br /> Home Phone:� � �- I �1 � —� ��-3 Alternate Phone: <br /> -Gontractor 1 Applicant�� ��r�ra*5,y`�"�,�^��� £ <br /> Contractor/App.: �;�v N �'� � G' '`� Contact Person: `-��-�k- ��� `� r' <br /> � L:•�'��i�Z�� \ �� �i <br /> Address: �`�`_� "�-� � �"�-cc-�-c� ��=-�1 State License #: l.—. � � � � <br /> City: �� `�� Zip: Expiration Date: =�L> � � <br /> Phone: '� L � 1 � �� �� Alternate Phone: <br /> � ��� <br /> �� � � 1 y G <br /> A, � �, �� ',�'Y '�R`� �re� '$ �P�'�5�4A � I'���..�1 +.. ,s ���� ���� P � _�� .,.,�'ia�'��..,,� �: <br /> i.�3 :A� 5;,1< <br /> � Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES ` �� � <br /> �� <br /> New or Replacement System $200.00 `� �,�:�: �% �' <br /> Repair Existing System 100.00 <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> Total $ <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />