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05/18/2015 14:15 952-955-5071 BURNS EXCAVATING PAGE 02 <br /> City o�OfOno +, Iit�Ry+C17Y'u�E`ON4�Y <br /> /^� P.O.Bpx 68 , `��j / �} <br /> �V 2754 Kelley pafkwaY l��'t�'sRA!t�W'�t�!�� P��!� /�— �/ J <br /> Grystal Bay,MN 55323 <br /> � j952)249-4800 �i��+� . �; ,� - � `.�''1) <br /> ��, : � �i � . <br /> ��� 5���� �`�'"''j ���/�//� <br /> �/_����� <br /> ' � �1'�J��f�°���, �t ='��_.��" <br /> CfTY �F ORONO—3�PTIG SYSTEM P�RN!'IT APPLICATION <br /> (,411 pemtlts must he appro�ed by the OnSite Septic Manager and/or Bulltling Offlciaq <br /> Site Address: <�!�U "Grt,;�,i��' I�,i '��L�. i�i�f�t� <br /> Owner: � ci��1�c'��hze�n� �Lnl�6���,�1�: Mailing Address: z�! ` _�" �, tz �y�fr� L�;�.'�� <br /> ci�Y� �1�� .. �Zip: � ,..� '�.3"7r <br /> Home Phone:� ,. �_ Alternate Phone: <br /> Con#ractor/ApP�- � ContaGt Person: _� ,"�-�.r�: ?�t�t���,�;,, <br /> Address: �j„��;� ('��i���-�/ ����( �j State �icense#; j�_� <br /> C�ry: � Zip: �;:5�l,at^> Explratlon Date: ����'�Zt�l� <br /> Phane: ���Z.� ���- �3 l 17 Alternate Phone; jQal Z} /4� "'.��/3�r�' <br /> ,,�,::='��,��:�� <br /> � Residential ❑ Commercial ❑ Other <br /> r <br /> New or Repiacement System $4QO.d0 � � <br /> F2epair�xis#ing System 100.00 <br /> (Tanks or Qrainfleld) <br /> State Surcharge 5.00 5.00 <br /> T�t91 4 ' r- �:a.� <br /> 1 /2 <br />