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(iTpdated 5/3/02) <br /> CITY OF ORONO APPLICATION FOR UTILITY PERMITS <br /> Box 66 (2750 Kelley Parkway) SEWER/WATER& SAC <br /> Crystal Bay, MN 55323 <br /> GENERAL IIV"FORMATION <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. Permit 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 /> �. Work must not begin unless the pernut card is available on the job site. <br /> 5. Utility connection pernuts 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 Departrnent. Issuance of a permit 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: �'t{'�� CcS�.c., Pf K� r <br /> Occupancy Type: Residential Commercial <br /> Owner's Name: 'W�s � re.,,��., r3 ��� Phone Number:`�5�-� 47% - oG i"� <br /> Mailing Address: �b►� ,co Pf (�J City: �«�.�c� Zip: <br /> Contractor's Name: �on�� �,1� ' Phone Number: �is:3 ��a��raa� <br /> Mailing Address: �.� 5 � �Z�' 0 City: M;�ra ��.<�'� Zip:SS 6� <br /> � <br /> ,—,// Y <br /> PERMIT TYPE �c.;onnections ❑Repairs ❑Disconnect (Check One) <br /> __._----•�-�" <br /> SAC Charge (2002 rate $1,200.00) $ (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 /> � �� <br /> Municipal Sewer Co ection/Disconnect/Repair($35.00 per stub) $ � .-� <br /> pipe size�nches; material Schd 40 air tested; cast iron <br /> Municipal Water Con ection/Disconnect/Repair ($35.00 per stub) $ �� ' <br /> �� <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 $ l � ' � <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 pemut requested. <br /> 3. PostaQe & Handlin� (Only mail-in applications) $ 1.50 (Mail In Only) <br /> 4. TOTAL PERMIT FEE (add lines 1-3 above) $ �� �-� <br /> -���� <br /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do all work in strict � <br /> accardance 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 /> � „ <br /> Si ature of A licant: ��/��� Date: /�%�.;? /-�`` <br /> � PP <br />