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♦ <br /> ** ATTENTION APPLICANT ** I ' , <br /> _ Fill in all appropriate blanks and check all appro rip 'ate boxes. _ __' <br /> I will be installing the following: <br /> Tanks <br /> ❑ Precast Concret ❑ Fiberglass ❑ Plastic ❑ Other <br /> Qist manufacturer) <br /> Number of Tanks: <br /> Size of Ta`nks: <br /> Treatment System L��� „ � �`t <br /> _� � �� � <br /> Trenches s.f. „�,U.,. <br /> ,/� � S�Y'�' -o <br /> � Mound �-C� � s.f. S ./� `�`� <br /> Gravel less s.f. � ���'� / <br /> � � � � � �� <br /> Chamber s.f. � �' <br /> �%l <br /> NOTE: The contractor is required to provide an As-Built of the system before the <br /> final inspection. <br /> The undersigned hereby applies to the City of Orono for issuance of a septic system <br /> installation permit, agrees to do all the work in strict accordance with ordinances of the City <br /> and regulations of the State of Minnesota and certifies that all statements made on this <br /> application are complete true a o ect. <br /> Signature of Applicant Date: � 1 — � / �� <br /> MPCA License No.: C�-P ��� � <br /> Staff Review: �Accept ❑ Denied <br /> Reviewer: ���� Date: � / �C; -`� <br /> Reason for Denial: <br /> Comments (to be printed on inspection card): <br /> W:\(Permits)\Septic Permit Application-Updated Surcharge 07-28-11.doc <br /> 2 � 2 <br />