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I <br /> ' �Q�� City of Orono F R C USE ONLY <br /> P.O. Box 66 / 7� <br /> ���.,, e � 2750 Kelley Parkway Date Received� �Y Permit#OZ�`���� � <br /> ��"���`' Crystal Bay, MN 55323 ��2��� <br /> �Y:.:F,' ,� <br /> ��08�0� (952)249-4600 Amount: <br /> /U...S,Ol� <br /> CITY OF ORONO - SEPTIC SYSTEM PERMIT APPLICATION <br /> (All permits must be approved by the On-Site Septic Manager and/or Building Official) <br /> Job Site I Owner ��nfiormation:.�� � ����� �� � � � <br /> Site Address: <br /> Z `� �-1 O �c,v�✓�`��` 5��c�-�' � r� , <br /> Owner: (9c^Y�� �U�S ��� � Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/Applicant Inforrnation: <br /> � <br /> �t � v�S Vc,�� <br /> Contractor/App.: � � Contact Person: <br /> � ` <br /> Address: Z � � �Z " s�f S � State License #: � � � <br /> City: /������- Zip: ����� Expiration Date: `Ls� � '�-- <br /> Phone: `?lp �j -- �7f��- /' 7�6 �- Alternate Phone: <br /> t�,..,,�„ : TYPES OF,OC'CUPAN,CY <br /> Residential ❑ Commercial ❑ Other <br /> PERMIT TYPE AND FEES ! <br /> New or Replacement System $200.00 <br /> Repair Existing System 100.00 ��' � <br /> (Tanks or Drainfield) <br /> State Surcharge 5.00 5.00 <br /> �-- <br /> Tota� $ / l.� S <br /> W:\(Perrnits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 1 / 2 <br />