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� <br /> � <br /> ** ATTENTION APPLICANT �`* <br /> Fill in.all appropriate blanks and check all ap ro riate boxes. I ' <br /> I will be installing the following: <br /> T ks <br /> �Precast Concrete ❑ Fiberglass ❑ Plastic ❑ Other <br /> � (list manufacturer) <br /> ��i �� <br /> Numb'er of Tanks: � �U s�f �`- �3vv��l�'T <br /> ,1 � <br /> Size of Tanksx s� l�C� � � 3 c�v � �'7-- <br /> Treatment System <br /> Trenches s.f. <br /> �� Mound � �Us.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 co , d rrect:� <br /> Signature of Applicant � � Date: / a '� �` �' �2-� <br /> MPCA License No.: �-- `� �� <br /> Staff Review: Accept ❑ Denied <br /> ' ,; �� - %�-l�-� <br /> Reviewer: �' �� Date: � <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): ��� � � � �l� � �`• � � 'f� �-%t.� <br /> 1-� '{ `'� e` S 'r (� ' � �'1/��i j�; � �'_ ���,/� � � cZ �C� �� <br /> �-/�S"1��} ( ( <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />