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Clty ot Ororlo FOR° , .1l9�,�N �r /� <br /> $�'�0 P.O.BaxBB ;f aDe.Rebeived� �! �- �b Pemift� �� � �7� <br /> 0 275U KeUey Parkway � � ') <br /> Cryaiel Bay,MN 3`3323 �O'.5v <br /> � � (952)248-4800 �1mouM; . 3�_ <br /> ' <br /> CIT1� (�F �a�NO-3EPTI� SYSTEM P�RMIT.APPLICATION <br /> (All pertnits muet be approved by the On-Site Septic Man�er and/o�Building OPfiGaI) <br /> ° .}� .,�a, ;�:-�'.:�'�'�".�'-°' <br /> 4,�,:�w "�!{�o.�'.: M����" <br /> Slte Address: 650 61G ISl.AND <br /> i <br /> Owne� �IM JOWNSON/CINDA COLI.iNs Ma�ling Address_ <br /> City_ Zip; <br /> �s�2)2s5-�9�z Alt�mate Phone: �612�e�7=�ae3 <br /> HQme Ph4ne: ......_ .... .. <br /> � , , z " � <br /> ,< <br /> �' �:��'�<��`r���;:. <br /> Contractor/App:: <br /> ABLE EXCAVATtON CO�N1t8Gt PerSon: WAYNE OPHEIM <br /> Address: �5630 OLD sRiCK YRD RD � �g9a <br /> St�te License#: <br /> ,. <br /> SHAKOPEE Z� 55379 EX�irat�on Date: �oizs��o <br /> City: P= -- � <br /> � <br /> Phane; (952)445-7432 Alt�rnate Phone� �;1�^� 3� -i y�Y <br /> ��i> <br /> ,,,,. �,�.. ,s�y�A � ., �6.�aa: <br /> . , , . <br /> . . ,.{ �;�:�.S°�. �, i.;R3 �,., 8:� �5��} Y� r !r .Fj'�'f�ji,yll <br /> �: -'�; L 41 �;�,tM'j'�A� ��.kJ�r! , ±r,��.�� ;;�. .�.�:'�'s;:' .��:i .���. <br /> 0 Residential [� Commercial ❑`i Other <br /> y, '�F �i g,� Y)��r�� y��1 �j`i li�� �� �; 1�{,,)Eg,Y����y'�`i�'.1� • <br /> �'7��;E�' �'.' ��"it�ti�Sc.,{ '�''�r �N'1`3�*��'t,3.. �i�`�<�'7"�;;� ry� �t^,.,�' `,�..�b, ;�v.n�'�..�yfF'�15!f%^�,�'v�1;�,;y �'iTa;,. <br /> M.!. <br /> p .�N.�,Y":lT.i15�':..lP':�.:�li\�7 Y� .•�. <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 _ <br /> (Tanks or Drainfield) <br /> State Surcharge .50 ' .50 <br /> �200.50 <br /> Tatal �� �' <br /> ; <br /> V1(Pem►k�s�\3epiic permh Applicsuon-New Perrnit Fees 2009.doc <br /> 1 �2 <br /> ; <br />