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(Updated 1/5/04) <br /> � <br /> CITY Q� ORONO APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER & SAC <br /> Crystal Bay, MN 55323 <br /> GENERAL INFORI'IATION <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 belo�v. Pernut cards will be seut by rehirn 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 peinut card is available on the job site. <br /> 5. Utility coiuiection pernuts may Ue issued to licensed conri-actors 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 Depai�inent. Issuance of a pemut does not grant this approval. <br /> 7. All�vork must Ue done in accordauce with State Code requirements. <br /> S. All work nlust be inspected before it is covered. Call(952)249-4600,24 hour notice required. <br /> JOB SITE ADDRESS: ,-?�?� � �1<< �C.-v r� ��' `� <br /> Occupancy Type: Residential Commercial <br /> Owner's Name:��,f:3��� u� � ��'� � � Phone Numbe►•: <br /> Mailing Address: City: Zip: <br /> Contractor's Name: �������J�� �S �L� Phone Numbei: �a�_?��� - �ls=�� <br /> Nlailing Address: L� -'�'l L�� i.='�� �S City• ,�-:�� 7 Zip; `_>> 36`t <br /> PERMIT TYPE ❑ Coiulections ❑Repairs �sconnect (Check One) <br /> SAC Charge (2003 rate $1,350.00) $ (Set Rate) <br /> Sac Charge must accompany all sewer pennit applications unless prepaid. <br /> (If not p�-epaid, a sewer connection will not be issued) <br /> Municipal Sewer i��ection/Discan-r�e�IRepair ($35.00 per stub) $ <br /> pipe size-��inches; material Schd 40 air tested; 'l cast iron <br /> Municipal W1ter �onnection/�`'1srniu�ect'1Repair ($35.00 per stub) $ <br /> pipe size -1 inches; inaterial�opper; other <br /> WATER METERS must be picked up and paid for at City Hall. <br /> Water meters must be set and sealed by Orouo Water Department <br /> (952-249-4600) upon completion of ineter installation. <br /> REQUIRED minimwn setbacks from drain field and septic tanks = 75' <br /> REQUIRED setback from sewer line =20' <br /> PERMIT FEE CALCULATION <br /> 1. Subtotal of above pennit requested $ <br /> 2. State Surcharae $ .50 (Minimum) <br /> The State Building Code Division Surcharge of$.50 per pernut inust be <br /> included for each well,sewer and water connection perxnit requested. <br /> 3. Postage & 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 <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 complete, true and correct. ,,, � <br /> , , <br /> � ---��% - ��c, <br /> Signature of Applicant: ._����� Date: � � <br />