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� <br /> r <br /> �0 City of Orono FOR CITY USE ONLY <br /> ��� P.O. Box66 !O/q a��d_ �A� <br /> 2750 Kelley Parkway Date Received: r / ermit# � <br /> a �t*<� Crystal Bay, MN 55323 <br /> ������ � Amount: � <br /> � '^�������.$o (952)249-4600 <br /> �Reexo <br /> �2`�� <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 /> Job Site / Or�iner Ir��`������n � � ` <br /> ,�M � r�P���� r� "�' <br /> � / `=cu <br /> Site Address: � � 5 � c�C.C� � <br /> Owner: �+u- `� �'"'� <br /> ��� � � / �c5 Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> �� <br /> Cor�tractor./.Ap�i��,� �f��t �r:, <br /> �,�..� .���� a �� <br /> Contractor/A . -e-S � �U^S Contact Person: � ti <br /> NN � �ti � <br /> Address: � � /�� �-�"f .S �'- State License #: �- � �-(.� <br /> ��" � � . ��� ` v <br /> City: /'��'hT�`'�'� Zip: 5 � .� ,� Expiration Date: �- � Z-- <br /> Phone: ?(2� -- `� 7� -/ 76 '�— Alternate Phone: ���O/Z 6�� -�S� <br /> z,�,y �'E����.,,� �III��., .�, . `���i-�E'>�I�'l�ii'� ..,'��°m�'�� d a�,%?�'`�+�^'�'i^�� �,�'«^��� .��`T, r G�W�,}, � k_ <br /> �esidential ❑ Commercial ❑ Other <br /> j PERMIT TYPE AND FEES <br /> r� <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 $ �--� 5 vJ� <br /> W:\(Perrnits)\Septic Perrnit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />