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' , , <br /> ** ATTENTION APPLICANT ** ', <br /> Fill in all a ro riate blanks and check ali a ro riate boxes. ' <br /> I will be installing the following: <br /> Tanks <br /> � Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> (list manufacturer) <br /> Number of Tanks: � <br /> Size of Tanks: � �`J C�-' - � <br /> ►(..)G C� c��4� �._���1^ \'� S���-�-'`�� <br /> Treatment System <br /> Trenches s.f. <br /> � Mound ��� '�� �� s.f. <br /> Gravel less s.f. <br /> Chamber s.f. <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection. <br /> The undersigned hereby applies to the City of Orono for issuance of a septic system <br /> installation permit, agrees to do all the work in strict accordance with ordinances of the City <br /> and regulations of the State of Minnesota and certifies that all statements made on this <br /> application are complete, trtxe and correct: <br /> , ., � ; �^ �•� _ � <br /> - ` <br /> SignatureofApplicar�,�� �°�'�.f`-�" l�' ;� Date: ���;- L� l � <br /> J � � <br /> MPCA License No.: �- �� � � <br /> Staff Review: Q Accept ❑ Denied <br /> � � <br /> Reviewer: �/ !�� ,(��� � Date: r � ' / - � ! <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />