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(iJpdated 1/5/04) <br /> CITY +DF �ORONO APPLICATION FOR UTILITY PER��ITS <br /> Box 66 (2750 Kelley Parkway) SEWERJWATER& SAC <br /> Crystal Bay, MN 55323 <br /> . <br /> �FNERAL INFORMATION <br /> 1. You may apply for utility pemuts 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 da�- : <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 pernut 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\OT EXCAVATE IN ANY STREET Ai�'D <br /> DO NOT TAP ANY MAIN without express approval of the Public Works Department. Issuance of a pemut 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: ���� C-�1 e`�� � �- <br /> Occupancy Type: esidential Commercial <br /> Owner's Name: �C'�c� ���0 m�w Phone Number: <br /> Mailing Address: City: Zip: <br /> Contractor'sName: mc', (Z�rtc� PhoneNumber: <br /> l�Iailing Address: 2h0 D C��-P� s �r, �r,����` City: Zip: <br /> �a � SSytI <br /> PERMIT TYPE ❑ Connections �Repairs ❑Disconnect (Check One) <br /> SAC Charge (2003 rate $1,350.00) $ (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 /> r <br /> l�Iunicipal Sewer Connection/Disconnect/Repair ($35.00 per stub) $ <br /> pipe size inches; material Schd 40 air tested; cast iron <br /> Municipal Water Connection/Disconnect/Repair ($35.00 per stub) � <br /> pipe size inches; material copper; other <br /> `VATER METERS must be picked up and paid for at City Hall. , <br /> �Vater 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 = 7S <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 permit 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 /> The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, a�-ees to do all work in strict � <br /> accordance with the ordinances of the City and the r ulations of the State of Minnesota, and certifies that all statements = <br /> made on this application a co lete, true`anc�c�rr�, <br /> \ � � ; <br /> � , <br /> \ � <br /> Signature of Applicant: Date: �.� <br />