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** 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 /> T�nks ` <br /> Precast Concrete ❑ Fiberglass ❑ Plastic Other �vJ U��'�'��S`C� <br /> (list manufacturer) <br /> Number of Tanks: � ►3��.S�� <br /> Size of Tanks: ���� I ��G ��G� `�A^ �S <br /> Treatment System <br /> Trenches s.f. <br /> ✓ Mound . c � 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, true and correct. <br /> Signature of Applicant Date: <br /> MPCA License No.: UI "I� <br /> Staff Review: Accept ❑ Denied <br /> Reviewer: ��� Date: � " � �'�� <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> T,L,S��-,�t �� � �� �A- ► t ��' So : � S U e�',� �, c� � �� <br /> �3�F����� 5.-t��r c� � I��o��-� S`t S-l�✓1�� <br /> Reset Form <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 7-1-10.doc <br /> 2 � 2 <br />