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CITY OF ORONO * Z QJ 1 5 - 0 0 6 1 9 * <br /> 2750 KELLEY PARKWAY DATE ISSUED: OS/26/2015 <br /> ' ' ORONO, MN 55356- <br /> (952) 249-4600 FAX: (952) 249-4616 <br /> ADDRESS : 2450 COUNTRYSIDE DR <br /> PIN : 04-117-23-11-0004 <br /> LEGAL DESC : COUNTRYSIDE MANOR <br /> : LOT 002 BLOCK 001 <br /> PERMIT TYPE : SEPTIC <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : NEW OR REPLACEMENT(SEPTIC SYSTEM) <br /> ACTIVITY : MOUND SYSTEM-SEPTIC <br /> APPLICANT SEPTIC NEW OR REPLACEMENT 400.00 <br /> STATE SURCHARGE SEPTIC 5.00 <br /> BURNS EXCAVATING, INC. TOTAL 405.00 <br /> 3470 CO. RD 21 <br /> MAYER, MN 55360- Payment(s) <br /> (612)685-4303 CHECK 26525 405.00 <br /> Minnesota State License#: SW-1888 <br /> OWNER <br /> & S GRANDE, LORRAINE KRETCHMAN <br /> 2450 COUNTRYSIDE DR <br /> LONG LAKE, MN 55356- <br /> AGREEMENT AND SWORN STATEMENT <br /> The work for which this permit is issued shall be performed according to <br /> the approved plans and specifications,applicable City approvals,and the <br /> State Building Code. This permit is for only the work described and does <br /> not grant permission for additional or celated work which requires separate <br /> permits. All provisions of laws and ordinances governing this type orwork <br /> shall be compied with whether or not specified herein.This permit will <br /> expire and become null and void if construction authorized is not <br /> commenced within 180 days of the date of issuance,or if construction is <br /> suspended for a period of 180 days at any[ime afrer work has commenced. <br /> The applicant is responsible for assuring all required inspections are <br /> requested in conformance with the State Building Code.This permit may be <br /> revoked at any time for due cause. <br /> - _ � S �-�i�� <br /> Applicant Permitee Signature Date Issued By Signature Date <br />