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(ITpdated 6/2/03) <br /> CITY OT ORONO APPLICATION FOR UTILITY PERMITS <br /> Boai66 �50 Kelley Parkway) SEWER/WATER& SAC � / j/vo J p <br /> Crystal Bay, MN 55323 <br /> ���c� 3 �(� <br /> GENERAL INFORVIATION <br /> 1. You may apply for utility pernuts by mail or in person at the City offices. <br /> 2. Mailed in applications are subject to the postage and handling fee shown below. Pernut cards will be sent by return mail the same day <br /> the application is received. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. Work must not begin unless the 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(952-249-4600)for utility stub as-built locations. DO NOT EXCAVATE IN ANY STREET AND <br /> DO NOT TAP ANY MAIN without express approval of the Public Works Department. Issuance of a pernut does not grant this approval. <br /> 7. All work must be done in accordance with State Code requirements. <br /> 8. All work must be inspected before it is covered. Call(952)249-4600,24 hour notice required. <br /> JOB SITE ADDRESS: S Sc�<<�G� /��-b,�.,� �G. <br /> Occupancy Type: k Residential Cornmercial <br /> Owner's Name: ��,��g G�i►� � ,`S„�, Phone Number: `y��Z- y7�-��9/ <br /> Mailing Address: � S G 6r�,��,/�l City: ��-,,�,� Zip: S s�s� <br /> Contractor'sNami�d /�/,�-,�/,���°�s PhoneNumber: -r'jSZ-�j��-7zy7 <br /> Mailing Address: 3�/o ro. �� lU/ City:����— Zip: S S'��'�� <br /> PERMIT TYPE �Connections ❑Repairs ❑Disconnect (Check One) <br /> SAC Charge (2003 rate $1,275.00) $ (Set Rate) <br /> Sac Charge must accompany all sewer permit applications unless prepaid. <br /> (If not prepaid, a sewer connection will not be issued) <br /> Municipal Sewer Connection/Disconnect/Repair($35.00 per stub) $ <br /> pipe size �I L/ , inches; material Schd 40 air tested; cast iron <br /> �i <br /> .�Iunicipal Water Connection/Disconnect/Repair ($35.00 per stub) $ <br /> pipe size inches; material copper; other <br /> WATER METERS must be picked up and paid for at City Hall. <br /> Water meters must be set and sealed by Orono Water Department <br /> (952-249-4600) upon completion of ineter installation. <br /> REQUIRED minimum setbacks from drain field and septic tanks= 75' <br /> REQUIRED setback from sewer line=20' <br /> PERMIT FEE CALCULATION <br /> 1. Subtotal of above permit requested $ <br /> 2. State Surchar�e $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per pernut must be <br /> included for each well,sewer and water connection permit requested. <br /> 3. Posta�e &Handlin�(Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT FEE (add lines 1-3 above) $ <br /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do all work in strict t <br /> accordance with the ordinances of the City and the regulations of the State of Minnesota, and certifies that all statements : <br /> made on this application are co lete, true and correct. <br /> Signature of Applicant: ��%��� .cr--- Date: � � � l�3 <br />